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ANAESTHETICS 


ANESTHETICS 


USES  AND  ADMINISTRATION 


BY 

DUDLEY   WILMOT   BUXTON,   M.D.,   B.S. 

MEMBER    OF    THE     ROYAL   COLLEGE     OF    PHYSICIANS;     MEMBER    OF     THE    ROYAL 
COLLEGE    OF    SURGEONS    OF    ENGLAND;    ADMINISTRATOR    OF  ANAESTHE- 
TICS   AND   LECTURER    IN    UNIVERSITY    COLLEGE    HOSPITAL,  THE 
.NATIONAL    HOSPITAL     FOR    PARALYSIS     AND    EPILEPSY, 
QUEEN'S    SQUARE,    AND     THE    DENTAL     HOSPITAL 
OF    LONDON 


SECOND    EDITION 


PHILADELPHIA 

P.   BLAKISTON,    SON   &   Co 

No.   1012  Walnut  Street 

1892 


-Of 

If0!*- 


PREFACE  TO  SECOND  EDITION. 


In  the  present  edition  the  bulk  of  the  matter  has 
been  recast,  and  materially  added  to,  with  a  view  to 
increase  its  utility.  The  uniformly  kind  aud  sugges- 
tive criticisms  of  the  first  edition  have  aided  me,  and 
I  have  in  many  cases  adopted  improvements  proposed 
by  correspondents  and  reviewers,  notably  by  supplying 
woodcuts  of  most  of  the  apparatus  described.  In  my 
former  edition,  the  descriptions  were  given  almost  in 
the  ipsissima  verba  of  the  inventors,  as  it  appeared  to 
me  that  they,  if  anyone,  should  know  how  to  describe 
their  own  ideas.  In  the  present  edition  these  de- 
scriptions have,  however,  been  altered  to  render  them 
it  is  hoped  more  plain. 

When  opinions  are  at  variance  about  the  action  of 
an  anaesthetic,  or  the  value  of  a  method,  I  have  en- 
deavoured  to  present    the    arguments    fairly,   but   as 


VI  PREFACE. 

the  book  is  intended  rather  as  a  practical  manual 
than  as  a  disputatious  treatise,  all  discussions  have 
necessarily  been  curtailed.  While  many  of  the  illus- 
trations are  original,  some  are  lent  by  the  courtesy 
of  the  firms  who  make  the  apparatus  they  depict,  or 
are  placed  at  my  disposal  by  the  kindness  of  pro- 
fessional colleagues,  and  to  all  of  these  I  tender  my 
thanks. 

82  Mortimer  Street, 

Cavendish  Square,  W. 
June,  1892. 


PREFACE  TO  FIRST  EDITION. 


The  introduction  of  anaesthetics,  which  has  done  so 
much  to  rob  surgery  of  its  horrors,  alike  for  the  patient 
and  the  operator,  has  created  a  great  demand  for  per- 
sons capable  of  administering  these  pain- destroying 
agents,  without  unfortunately  exciting,  as  a  rule,  so 
great  a  sense  of  responsibility  in  the  administrator 
as  his  difficult  and  dangerous  duties  should  render 
obligatory. 

It  is  surprising  that  surgeons  who  have  witnessed 
the  attempts  of  novices  to  give  anaesthetics,  should  hold 
any  view  save  that  no  one  is  capable  of  safely  giving 
any  anaesthetic  unless  he  has  been  carefully  taught  and 
has  obtained  considerable  experience. 

Personally,  I  do  not  believe  that  the  perusal  of  any 
book  will  enable  a  medical  man  to  do  more  than  learn 
the  rudiments  of  anaesthetising  ;   but  a  book  may  be  of 


Ylil  PREFACE. 

undoubted  service  to  the  thoughtful  student  or  practi- 
tioner, in  enabling  him  to  appreciate  the  dangers  inci- 
dent to,  the  caution  necessary  in  anaesthetising,  and 
to  grasp  the  rationale  of  the  various  methods  of  pro- 
cedure. 

Unfortunately,  the  subject  of  anaesthetics  has  for 
some  years  escaped  the  notice  of  the  scientific  side  of 
the  profession,  and  has  as  a  natural  result  been  rele- 
gated to  the  dcmain  of  routine. 

In  this  book,  which  has  been  written  purely  from  the 
stand-point  of  every  day  practice,  1  have  attempted  to 
indicate  that  the  matter  dealt  with  has  a  scientific  as 
well  as  a  work-a-day  aspect,  and  that  he  who  desires 
to  be  more  than  a  mechanical  (and  hence  dangerous) 
administrator  of  anaesthetics,  must  be  scientifically,  as 
well  as  practically,  educated  in  his  art. 


TABLE  OF  CONTENTS. 


CHAPTER  I. 

PAGE 

Historical — Nepenthes— Anaesthetics  among  the  Egyptians, 
Assyrians,  and  Chinese — Opium — Cannabis  indica— Carbonic 
dioxide — Ansesthesia  by  compression  of  blood-vessels — Ditto 
of  nerves — Mesmerism — Hypnotism — Humphry  Davy  and 
nitrous  oxide — Horace  Wells'  use  of  gas — Its  introduction 
into  London — Discovery  of  ether — Morton  and  ether — First 
administration  of  ether  in  London — Simpson's  employment 
of  chloroform  as  an  anaesthetic — Flouren's  researches — 
Snow— Clover's  work — Pollock  and  Haward's  work — The 
"Glasgow  Committee" — The  Nizam  of  Hyderabad — The 
Hyderabad  Commission  .  .  .  .  .  .1 


CHAPTER   II. 

Pekpaeation  of  a  patient  for  an  anesthetic  and  choice 
of  the  an/Esthetic — Best  time  for  giving  anaesthetics — 
Directions  about  food — Dietary — Choice  of  anaesthetic  for 
infants  and  children — For  adults — For  persons  with  puimon- 


CONTENTS. 

PAGE 

ary  disease — Heart  disease — Renal  disease — Arterial  disease 
— For  the  aged — In  collapse — For  pregnant  women — For 
operations  about  month,  nose,  pharynx — For  operations 
on  the  eyes — On  the  thorax — In  abdominal  surgery — In 
parturition  .  .  .  .  .  .  .14 


CHAPTER   III. 

Nitrous  oxide  gas — Chemical  and  physical  properties — Prepar. 
ation — Impurities— Physiological  action — Vegetable  kingdom 
— Animal  kingdom — Human  subject — In  general  surgery — 
In  dental  surgery — Apparatus  required — Dudley  Buxton's 
apparatus — Clover's  inhaler — Administration  of — Special  in- 
struments, gags,  mouth  openers,  dental  props,  tongue 
forceps,  &c. — After  effects — Dangers  attending  administra- 
tion— Their  treatment— Is  nitrous  oxide  dangerous  ? — to 
pregnant  women — The  aged  — In  lung  disease — In  hearts  dis- 
ease—Deaths from — Paul  Bert's  method— Dr.  Hewitt's  oxy- 
gen and  nitrous  oxide  mixture  .  .  .  .     27 


CHAPTER   IV. 

Ether — Discovery — Chemical  and  physical  properties— Its  uses — 
Physiological  action  —Methods  of  administration— Inhalers — 
EfFects  of  ether  inhalation— Rectal  etherisation  —  Dangers  and 
accidents  to  respiration,  to  heart,  &c. — Treatment — After 
effects  of  ether — Treatment        ...  .     f>7 


CONTENTS.  XI 


CHAPTER  V. 

PAGE 

Chloroform — Its  discovery — Chemical  and  physical  properties — 
Preparation  —  Impurities  —  Tests  —  Physiological  action  — 
Upon  the  human  subject — Administration  of — Clover's  ap- 
paratus— Inhalers— Snow's,  Sansom's,  Junker's,  Dudley 
Buxton's,  Krohne's — The  open  method — Method  by  hypo- 
dermic injection — Method  of  definite  mixtures— Complica- 
tions under  chloroform — Syncope — Treatment — Interference 
with  respiration — Mechanical — Vital — Treatment — Entrance 
of  foreign  bodies  into  air  passages  under  chloroform — Treat- 
ment—  After-effects  of  chloroform;  vomiting;  hysteria; 
jaundice;  albuminuria;  astigmatism;  insanity  .  .     94 


CHAPTER  VI. 

Amtlene — Chemical  and  physical  properties — Preparation — Phy- 
siological action — Mode  of  administration — After  effects  and 
dangers— Tneir  treatment — Ethidene  chloride— Physical 
and  chemical  properties— Physiological  action — Methods  of 
administration— Accidents  and  after  effects — Hydrobrouic 
ether — Chemical  and  physical  properties — Physiological 
action — Cases  in  which  suitable — Dangers  from  complica- 
tions under — Their  treatment     .....   131 


Xll  CONTENTS. 


CHAPTEK   YII. 

PAGE 

Anesthetic  mixtures— A.  C.  E.  mixture — Vienna  mixture— 
Linbart's  mixture — Methylene — Billroth's  mixture — Martin- 
dale's  A.  C.  E.  mixture — Method  of  employing  the  A.  C.  E. 
mixture — After  effects — Eichardson's  mixture— Methods  of 
employment  for  other  mixtures — Their  relative  values  and 
dangers  —  Morphine  and  chloroform — When  applicable — 
Method  of  administration — Dangers — Chloroform,  morphine, 
and  atropine  mixture— Morphine  and  ether,  its  advantages 
and  drawbacks— Chloroform  and  amyl  nitrite— Mode  of 
application — Uses — Drawbacks— Physiological  action — Chlo- 
roform and  chloral— Mode  of  application— Advantages  and 
drawbacks — Chloroform,  chloral,  and  morphine — Cocaine  and 
chloroform— Chloral  hydrate  and  ether— Mode  of  employ- 
ment— Dangers  of— Nitrous  oxide  and  ether    .  .  .  142 


CHAPTER  VIII. 

ANESTHETICS  in  obstetric  practice — Choice  of  anaesthetic — 
Stage  in  labour  when  to  be  used— In  normal  labour — Rules 
guiding  administration — Objections  considered — Method  of 
administration — Obstetric  operations— For  turning — For  ex- 
traction by  forceps— Craniotomy — Hour-glass  contraction — 
After  effects— Treatment  .  .  .  .  .lei 


CONTENTS.  Xlll 

CHAPTEE   IX. 

PAGE 

Anaesthetics  in  Special  Surgery — In  Brain  Surgery— In 
Ophthalmic  practice — For  operations  ahout  the  Mouth,  Jaws, 
and  Respiratorytract — Rectal  Etherisation  in  Oral  Surgery — 
For  removal  of  Post-nasal  Adenoids — In  Dental  Surgery — 
Thoracic  Surgery — In  Abdominal  Surgery — In  Rectal  Sur- 
gery .  .  .  .  .  .  .  .162 


CHAPTEE   X. 

Accidents  of  anesthesia  and  how  to  treat  theji — Foreign 
bodies  in  air  passages —Artificial  teeth — Gags — Sponges  — 
Precautions  against  such  accidents — Dangers  from  posture 
of  patient — Paralysis  of  respiratory  centre — Treatment  of 
accidents — Tracheotomy — Spasm  of  Jarynx — Laryngotomy — 
Artificial  respiration — Sylvester's  method — Howard's  method 
— Accidents  due  to  syncope — Treatment — Apoplectic  seiz- 
ures— Epileptic  seizures — 'Hysterical  seizures  .  .  .  171 


CHAPTEE   XI. 

Local  Anesthesia — Cocaine — Physical  properties  and  prepar- 
ations—Physiological action — Method  of  employment — As  a 
paint,  by  instillation,  as  a  spray,  hypodermically — Coming's 
method — Indication  for  use  of  cocaine  in  ophthalmic  prac- 
tice—In operations  about  the  larynx,  pharynx — In  minor 
surgery— Operation  on  the  urino-generative  tract — In  Dental 
Surgery — In  major  operations — Accidents  and  after  effects  of 


XIV  CONTENTS. 

PAGE 

Cocaine — Their  treatment — Fatalities  under  Cocaine — Bra- 
cine — Drumine  —  Ether  spray — Mode  of  application— Disad- 
vantages—Chloride  of  Methyl — Local  anaesthesia  by  alcohol 
— Ditto  by  carbolic  acid — Ditto  by  electricity— Ditto  by 
rhigoline — Ditto  by  Bisulphide  of  Carbon        .  ,  .  180 


CHAPTEE   XII. 

Medico-legal  aspects  of  the  administration  of  anaesthetics — 
Administrations  without  consent,  an  assault — Charges  of 
malpraxis — Commission  of  crimes  under  anaesthetics — Can  an 
anaesthetic  be  administered  without  consent  ? — Anaesthetising 
possible  during  sleep— Attempted  rape  under  anaesthetics — 
Erotic  hallucinations  under  anaesthetics — Robbery  under 
anaesthetics — Testimony  of  anaesthetised  persons  unsatis- 
factory— Death  under  anaesthetics — Relative  mortality  under 
various  anaesthetics — Responsibility  of  anaesthetist  —  Un- 
qualified persons  criminally  responsible — Dentists  and  anaes- 
thetics— Death  from  nitrous  oxide  gas — P.  M.  appearances — 
Deaths  from  ether — P.  M.  appearances — Detection  of  ether 
by  analysis— Deaths  due  to  chloroform — P.  M.  appearances — 
Detection  of  chloroform — Analysis  of  the  tissues — Self-indul- 
gence in  anaesthetics — Insanity  following  from  the  adminis- 
tration of  anaesthetics      ......  100 

Indkx    .........  217 


ANESTHETICS. 


Hi 


CHAPTEB  I. 

HlSTOKICAL. 

Means  for  producing  surgical  anaesthesia  were  practi- 
cally unknown  until  Wells  introduced,  nitrous  oxide, 
Morton  employed  ether,  and  Simpson  chloroform. 
'  With  the  first  employment  of  these  three  agents  com- 
mences the  history  of  artificial  anaesthesia,  although 
from  very  early  times  attempts  were  made  to  attain 
painlessness  during  surgical  operations. 
^Nepenthes  or  sedative  draughts  to  relieve  severe  pain 
are  mentioned  in  the  Odyssey — -Helen  seeks  to  "drown 

1  sense  of  woe"  and  assuage  the  sufferings  of 
Menelaus.     In   Egypt,    Cannabis    Indica,^he   modern 

aschish,  and  other  drugs,  were  similarly  used.  The 
Assyrians  and  ancient  Chinese  seem  to  have  employed 
various    drugs   with    a  view    of  relieving  the   pain    of 

ounds  and  such  rough  surgery  as  was  practised 
among  them.\  Opium,  Cannabis  Indica,  carbonic  di- 
oxide, and  deadly  nightshade,  were  advocated  in  various 
forms  to  achieve  this  object.  jPliny  and  Dioscorides 
describe  several  methods  in  vogue  among  the  Eomans 

and   other   nations   for  benumbing  parts  subjected  to 
^i^  ...  .      .  . 

incision  and  cauterisation.  Memphis  marble,  for  exam- 
ple, was  finely  powdered  and  applied  to  the  part,  while 
on  the  addition  of  vinegar  a  gas  was  given  off  (carbonic 

B 


2  ANESTHETICS. 

dioxide)  "which  rendered  the  part  slightly  anaesthetic. 
Various  members  of  the  Euphorbiacere,  Mandr agora, 
and  Solanaceous  plants,  were  also  employed  as  infu- 
sions, which  being  drunk  induced  some  narcotism. 
Attempts  at  anaesthesia  by  inhalation  were  very  early 
practised.  The  Scythians  burned  Cannabis  Indica  and 
inhaled  its  fumes,  to  alleviate  pain. 

In  more  modern  times  little  advance  was  made  until 
the  present  century.  Most  surgeons  were  contented  to 
put  their  patients  deeply  under  opium.  In  1G61, 
Ny  Greatrakes,  a  professional  "stroker,"  also  practised  an- 
aesthetic mesmerism.  He  performed  before  Charles  II. 
In  a  M.S.  dated  twenty  years  later,  one,  Denis  Papin, 
wrote  that  he  possessed  the  means  whereby  he  could 
abrogate  all  painful  sensations  during  a  surgical  opera- 
tion, but  what  his  method  was,  is  left  unexplained. 
*  In  the  16th  and  17th  centuries  Valverdi   and  others 

operated  upon  patients  stupefied  by  compression  of  the 
carotid  arteries,  so  depriving  the  brain  of  blood.  In 
this  practice  they  seem  to  have  been  anticipated  by 
the  Assyrians,  who  are  reported  to  have  compressed 
the  vessels  of  the  neck  to  render  painless  the  operation 
of  circumcision.  James  Moore,  an  English  surgeon,  in 
1784  revived  a  suggestion,  originally  made  by  Ambroise 
Pare,  that  compression  of  the  nerve-trunks  should  be 
practised  before  cutting  the  areas  supplied  by  them, 
and  John  Hunter  actually  took  advantage  of  the  plan, 
and  amputated  a  leg  in  St.  George's  Hospital  after 
firmly  compressing  the  crural  and  sciatic  nerves.  Mr. 
Moore  i  spr<   sed  himself  satisfied  with  the  result. 

A  departure  in  an  entirely  new  direction  was  made 
by  Meemer  and  his  followers,  who  averred  that  patients 
thrown    into    the    "  magnetic    state "     (i.e.  hypnotised) 


HISTORICAL.  6 

could  be  surgically  treated  without  any  pain  or  incon- 
venience. Long  before  Mesmer  lived,  a  belief  had  been 
current  that  the  natural  magnet  possessed  powers 
which  were  both  curative  of  disease  and  capable  of 
establishing  anaesthesia.  Thus  Cardan  (1584)  recounts 
how  the  magnet  could  be  employed  to  abrogate  pain. 
The  germs  of  the  facts  now  known  and  accepted  under 
the  terms  animal  magnetism  or  hypnotism  bore  a  fruit- 
ful harvest  of  windy  words,  Paracelsus,  Glocenius, 
Burgrave,  and  others,  contributing  largely  thereto.  By 
Anthony  Mesmer  (born  1734)  however,  the  matter  was 
advanced  from  theory  to  practice,  and  although  we  may 
carp  at  Mesmer  as  a  charlatan  and  quack,  we  must 
accord  to  him  a  meed  of  gratitude  for  establishing  upon 
a  practical  basis  a  science  which  before  his  age  was  lost 
in  useless  verbiage.  In  1766,  Mesmer  published  his 
work,  "The  Influence  of  the  Planets  in  the  Cure  of 
Disease,"  which  maintained  that  the  celestial  orbs 
exercised,  by  means  of  "animal  magnetism" — an  all- 
pervading  fluid,  an  influence  benign  or  malign  on 
human  beings.  Fourteen  years  later,  in  conjunction 
with  a  Jesuit  called  Father  Hell,  Mesmer  undertook 
the  cure  of  disease  by  means  at  first  of  the  magnet  and 
steel  tractors,  but  finally  of  manual  passes.  The 
plaudits  which  at  first  greeted  him  in  Vienna  were  ere 
long  changed  for  the  most  hostile  treatment,  the 
learned  bodies  of  his  own  and  other  countries  treating 
his  writings  with  contempt  and  himself  with  contumely. 
Leaving  Vienna,  Mesmer  exploited  Paris,  where  he 
founded  the  widely  famed  hospital  whereat  were  treated 
a  great  number  of  patients.  In  1785  a  royal  commission 
was  appointed  to  enquire  into  Mesmer's  pretentions, 
but  this  and  subsequent  commissions  unfortunately  con- 

b  2 


4  ANAESTHETICS. 

fused  the  issues  iu  question,  and  while  they  decided  that 
Mesuier  aud  his  immediate  adherents  were  unworthy  of 
credence,  they  failed  to  discriminate  the  substratum  of 
truth  underlying  their  teaching  and  practice.  After 
Mesiner's  downfall  the  subject  was  kept  before  the 
world  by  the  practice  of  the  Marquis  de  Puysequr  and 
the  somnambulists.  In  1829,  Cloquet  amputated  a 
breast,  the  patient  being  rendered  insensible  through 
having  been  thrown  into  the  hypnotic  state.  Elliotson, 
a  firm  believer  in  the  practical  uses  of  animal  mag- 
netism in  surgery,  employed  it  on  several  occasions 
with  success.  Braid,  of  Manchester,  in  1841  made 
considerable  trial  of  what  he  called  the  neurhyp- 
notic  trance  as  a  means  of  producing  surgical  anaes- 
thesia. Similar  experiments  were  carried  out  in  India 
by  Dr.  Esdaile,  who  performed  no  less  than  three 
hundred  operations  upon  patients  in  the  hypnotic  state. 
Spasmodic  attempts  have  from  time  to  time  been  made 
to  revive  th«j  practice  of  hypnotism  for  the  induction  of 
anaesthesia  with  but  partial  success.  It  has  been  found 
that  while  only  a  certain  number  of  persons  are  capable 
of  being  completely  hypnotised,  eve*,  these  as  a  rule 
require  several  seances  under  the  hands  of  the  magnet- 
iser  before  the  requisite  degree  of  insensibility  to  pain  is 
attained.  Again,  the  mental  state  thus  called  into 
existence  is  in  a  large  number  of  cases  highly  preju- 
dicial to  physical  and  moral  well-being,  and  hence  the 
consensus  of  opinion  at  present  goes  rather  adversely 
to  the  employment  of  hypnotism  in  anaesthetic  practice, 
save  in  very  exceptional  circumstances  and  under  <• 
fully  guarded  conditions. 

In  the  18th  century  the  history  of  discoveries  con- 
cerning anaesthetic   methods  becomes  merged  in   that 


HISTORICAL.  5 

of  the  progress  of  chemical  research.  Hales,  Lavoisier, 
Priestley,  and  Cavendish,  opened  up  rich  stores  of  know- 
ledge by  their  discoveries  among  the  gases.  Oxygen, 
nitrogen,  nitric  oxide,  were  prepared  and  closely  studied, 
and,  in  1772,  Priestley  added  nitrous  oxide  gas  to  the 
list.  Pneumatic  chemistry,  till  then  unknown,  became 
the  absorbing  theme  among  chemists,  while  physicians 
sought  to  bring  the  recent  discoveries  to  account  by 
pressing  these  gases  into  the  service  of  medicine.  Dr. 
Becldoes  in  1798,  assisted  with  finances  by  Wedgwood 
the  renowned  potter,  inaugurated  his  Pneumatic  Insti- 
tution at  Clifton,  where  he  proposed  to  treat  phthisis 
and  many  other  diseases  by  inhalations  of  various 
gases.  ' 

The  Pneumatic  Institute  is  interesting  mainly  be- 
cause its  first  superintendent  was  Humphry  Davy,  who 
prosecuted  therein  his  researches  concerning  nitrous 
oxide  and  other  gases.  In  1799,  Davy  discovered  that 
"  as  nitrous  oxide,  in  its  extensive  operation,  appears 
capable  of  destroying  physical  pain,  it  may  probably  be 
used  with  advantage  during  surgical  operations  in  which 
no  great  effusion  of  blood  takes  place."  Davy  substan- 
fciated  his  statements  by  most  careful  experiments  upon 
+he  lower  animals,  extending  Hales'  research,  which  had 
been  confined  to  mice,  and  demonstrating  many  facts 
the  practical  uses  of  which  were  not  appreciated  for 
more  than  forty  years  later.  But  his  philosophic  mind 
did  not  content  itself  with  limiting  his  experiments 
here ;  he  actually  inhaled  the  gas  and  found  its  influ- 
ence to  assuage  the  pains  of  toothache,  and  in  his 
"  Eesearches  "  are  recorded  his  own  sensations  and  the 
behaviour  of  others  after  inhaling  nitrous  oxide  gas. 
Early  in  the   nineteenth   century  Dr.  Hickmann   sng- 


O  ANESTHETICS. 

gested  that  a  painless  mode  of  operating  might  be 
achieved  by  the  patients'  inhaling  carbonic  acid  gas, 
but  his  proposal  met  with  scant  favour. 

The  discovery  made  by  Davy  was  not  brought  within 
the  field  of  practical  application  until  Horace  Wells,  a 
dentist  of  Hartford,  Connecticut,  conceived  the  idea  of 
using  nitrous  oxide  gas  as  an  anaesthetic  for  tooth  ex- 
traction. Wells  went  to  a  popular  lecture  delivered 
before  the  inhabitants  of  Hartford  by  a  Mr.  Colton,  an 
itinerant  lecturer  on  chemistry.  During  the  perform- 
ance one  of  the  audience  inhaled  an  impure  sample  of 
gas  and  became  very  excited.  In  the  course  of  his 
gyrations  this  individual  wounded  his  leg  but  felt  no 
pain,  a  circumstance  of  which  Wells  was  not  slow  to 
take  notice.  The  following  day,  Dec.  11th,  1814,  Mr. 
Colton  at  the  request  of  Wells  administered  gas  to  him, 
and  during  the  ensuing  unconsciousness,  a  Mr.  Riggs, 
another  dentist,  extracted  a  molar  from  Wells'  jaw. 
After  successfully  employing  gas  as  an  anaesthetic 
among  his  own  patients,  Wells  essayed  a  public 
demonstration  in  the  operating  theatre  of  the  Boston 
General  Hospital.  The  individual  upon  whom  this 
experiment  was  tried  was  not  rendered  completely 
unconscious,  and  gave  unequivocal  signs  of  having  felt 
pain.  This  failure  not  only  ruined  Wells,  who  died  in 
great  poverty  not  long  afterwards,  but  discredited 
nitrous  oxide  as  an  anaesthetic. 

Colton  subsequently  induced  various  dentists  to  ex- 
periment, and  in  18G7  he  was  able  to  give  a  record  of 
20,000  successful  cases.      In  1868*  the  anaesthetic  pro- 

*  Colton  while  in  Paris  met  with  a  well-known  dentist,  Dr.  Evans, 
mainly  to  whose  energy  and  munificence  Colton's  apparatus  travelled 
to  London,  where  the  merits  of  nitrous  oxide  gas  were  brought  before 
the  English  faculty. 


HISTORICAL.  7 

perties  of  nitrous  oxide  gas  were  successfully  demon- 
strated at  the  Dental  Hospital  of  London,  and  a 
committee  of  the  leading  English  dentists  was  formed. 
The  two  reports  published  by  these  gentlemen,  and 
read  before  the  Odontological  Society  of  Great  Britain, 
spoke  in  warmest  praise  of  the  agent,  and  practically 
established  its  claims  as  a  safe  and  efficient  anaesthetic 
for  short  operations,  in  spite  of  considerable  opposition 
on  the  part  of  certain  members  of  the  medical  pro- 
fession, who  denounced  nitrous  oxide  as  dangerous  and 
unsatisfactory. 

C  Ether  is  said  to  have  been  discovered  by  an  Arabian 
hemist,  Djabar  Yeber,  and  its  method  of  manufacture 
by  Dr.  Michael  Morris.  As  an  anaesthetic,  however,  it 
is  commonly  held  to  be  due  to  American  enterprise.  It 
was  fairly  well  known,  and  its  properties  recognised,  as 
early  as  1785,  when  Dr.  Pearson,  of  Birmingham,  em- 
ployed it  as  an  inhalation  for  asthma,  and  early  in  the 
present  century  it  was  used  in  the  treatment  of  phthisis. 
In  1818  a  paragraph  appeared  in  the  Journal  of  Science 
and  the  Arts,  which  although  unsigned  is  generally  sup- 
posed to  have  emanated  from  the  pen  of  Faraday ;  it 
runs : — "When  the  vapour  of  ether  is  mixed  with  com- 
mon air  and  inhaled,  it  produces  effects  very  similar  to 
those  occasioned  by  nitrous  oxide."  Then  follows  an 
account  of  an  experience  with  ether  ;  a  gentleman  who 
inhaled  became  "  lethargic,"  and  so  remained  for  thirty 
hours.  Facts  about  the  narcotic  properties  of  ether 
were  rapidly  brought  to  light,  and  the  writings  of  Oriila, 
Broclie,  Giacomini,  and  Christison,  all  give  more  or  less 
accurate  accounts  of  the  stupefying  effects  of  ether. 
About  the  year  1840  it  was  a  common  trick  at  lectures 
and  among  medical  students  to  inhale  ether-vapour  in 


8  ANESTHETICS. 

order  to  induce  exhilaration.  A  number  of  lads  were 
indulging  in  this  pastime  in  the  outskirts  of  Anderson, 
S.  C,  and  to  stimulate  further  their  mirth  seized  upon 
a  negro  boy  and  forced  him  to  inhale  ether,  pressing 
the  vapour  upon  him  until  he  became  deeply  narcotised 
and  apparently  dead.  In  an  hour,  however,  to  the 
delight  of  his  tormentors,  the  negro  resumed  conscious- 
ness. This  scene  impressed  itself  so  deeply  upon  one 
of  the  lads,  named  TVilhite,  that  when  three  years 
subsequently  he  became  the  pupil  of  a  Dr.  Long,  of 
Jefferson,  Jackson  County,  U.  S.  A.,  he  narrated  to 
him  his  experiences  of  ether.  As  a  result  Dr.  Long  in 
1842  administered  ether  to  a  patient,  and  while  he  was 
narcotised  removed  a  small  tumour.  The  same  sur- 
geon employed  ether  as  an  anaesthetic  on  several  sub- 
sequent occasions  with  a  like  success,  but  somehow  the 
matter  did  not  attract  any  particular  notice.  Other 
medical  men  also  about  this  time  employed  ether  for 
surgical  anaesthesia.  A  student  named  William  Clarke, 
in  1842,  administered  ether  at  Kochester,  New  York,  to 
a  patient  for  tooth  extraction,  and  Dr.  Marcy,  an 
American,  operated  upon  an  etherised  patient  in  1844. 

However,  the  employment  of  ether  as  an  anaesthetic 
is  more  usually  associated  with  the  name  of  Morton,  a 
dentist  of  Boston.  William  T.  G.  Morton  was  a  pupil 
of  Horace  Wells,  and  from  his  master  he  gathered  his 
first  impressions  concerning  artificial  anaesthesia.  It 
would  subserve  no  useful  purpose  to  open  up  the 
miserable  quarrels  and  recriminations  which  have  been 
connected  with  Morton  and  his  share  in  the  introduc- 
tion of  ether  as  an  anaesthetic.  I  will,  therefore,  merely 
state  the  facts  as  far  as  I  can  do  so  without  bias,  and 
after  reading  both  sides  of  the  controversy. 


HISTORICAL.  9 

Wells  made  Morton  his  partner  in  a  dental  practice 
he  proposed  to  start  in  Boston.  The  removal  from 
Hartford  to  Boston  was  consequent  upon  a  discovery 
Horace  Wells  had  made  of  some  solder  with  which  he 
hoped  to  achieve  great  things.  To  confirm  his  own 
estimate  of  the  value  of  this  solder  he  called  iu  a  Dr. 
Jackson,  a  scientific  chemist,  who  expressed  a  favour- 
able opinion.  However,  the  partners  soon  fell  out,  and 
Wells  returned  to  Hartford,  leaving  Morton  in  Boston. 
The  latter  asked  Wells  for  information  as  to  the  pro- 
duction of  nitrous  oxide,  and  was  by  him  referred  to 
Dr.  Jackson.  It  was  suggested  by  the  chemist  that 
trial  should  be  made  of  sulphuric  ether  instead  of 
laughing-gas,  since  it  was  more  easily  obtained.  Act- 
ing upon  the  suggestion,  ether  was  given  and  teeth 
were  extracted  without  pain.  This  success  was  followed 
by  a  public  demonstration,  October  17th,  1846,  in  the 
Massachusetts  General  Hospital,  when  Morton  adminis- 
tered ether,  and  Dr.  Warren,  a  well  known  surgeon, 
proceeded  to  operate.  The  experiment  was  repeated, 
and  each  time  proved  a  remarkable  success. 

In  England,  the  first  administration  of  ether  took 
place  in  Gower  Street,  London,  close  to  University 
College  Hospital,  "when  Mr.  Kobertson,  a  dentist,  gave 
ether  and  removed  some  teeth.  This  took  place  Dec. 
19th,  1846,  at  the  house  of  Dr.  Boot. 

On  December  21st,  Liston  amputated  through  the 
thigh  in  University  College  Hospital,  the  patient  being 
etherised.  Dr.  Snow,  early  in  1847,  commenced  the 
successful  administration  of  ether  in  St.  George's 
Hospital,  but  upon  the  introduction  of  chloroform  he 
gave  up  ether  for  its  more  savoury  but  less  safe  rival. 
On    January    19th,   1847,  Dr.   (afterwards    Sir   James 


10  ANESTHETICS. 

Young)    Simpson    administered   ether  to  a  woman  in 
childbirth.     Notwithstanding  favourable  experiences  of 
many,  ether  was  not  rendered  popular  for   some  years 
subsequently.     The  methods  in  vogue  for  its  adminis- 
tration were  far  from  satisfactory;   man}'  patients  never 
got  beyond  the  stage  of  exhilaration   and  wild  excite- 
ment,   and   their    struggles    and   bacchanalian    shouts 
were  pronounced  highly  embarrassing  to   the  presiding 
surgeon.     These  considerations  led  Liston   and  other 
eminent  surgeons  to  regard   ether  with  suspicion,  and 
made  them  diffident  in  invoking  its  aid  to  their   assist- 
ance.    However,  up    to  the  time  of   Simpson's  world- 
famed  pamphlet,  Xotice  of  a  new  ancestlietic  agent  as  a 
substitute  for   sulphuric  etJier  in  surgery   and   midwifery, 
November,  1847,  ether  was   slowly  but  surely  winning 
its  way  as  a   safe  and  trusty  anaesthetic.     With,  how- 
ever, the  introduction  of  chloroform,  came  the  coup  de 
t/race   to    ether.     With    an    almost   incredible   rapidity 
chloroform    supplanted   her    elder    sister,    not    only  in 
Great  Britain  but  almost   throughout   the    world ;    in 
America,  however,  many  surgeons  still  clung  to  ether. 
The   story  of  the  introduction  of  chloroform  is   soon 
told.     Sir  James  Y.  Simpson,  not  wholly  satisfied  with 
ether,    in    obstetric   practice,    ashed    Mr.    Waldie,    the 
.Master  of  the  Apothecaries'  Hall  of  Liverpool,  if  he,  as 
a  practical  pharmacist,  knew  a  substance  likely  to  be  of 
service    in    producing    anaesthesia.     Mr.  Waldie    being 
acquainted    with    the   composition   of   "  chloric   ether," 
suggested  that  its  "  active  principle,"  chloroform,  should 
be  prepared  from  it  and  used,     lie  never  carried  out 
his  promise  to  prepare  some,  and   so  the  desired  sub- 
stance was   obtained  in  Edinburgh,  and   Simpson  ex- 
perimenting found  its  use   perfectly   satisfactory.     This 


HISTORICAL.  11 

favourable  opinion  he  expressed  in  his  paper  read  before 
the  Medico- Chirurgical  Society  of  Edinburgh,  Nov.  10th, 
1847.    On  Nov.  15th,  1847,  Simpson  performed  at  Edin- 
burgh his  first  operation,  the  patient  being  under  the 
influence    of   chloroform.     It   is    curious  to  note   how 
narrowly  several  persons  escaped  discovering  the  value 
of  chloroform  as  an  anaesthetic.       Thus,  chloric  ether, 
a  twelve  per  cent,  solution  of  chloroform  (by  volume)  in 
spirits  of  wine,  was  employed  by  Dr.  Bigelow,  of  Boston, 
but  without  success.     Jacob  Bell,  of  London,  however, 
actually  produced  insensibility  by  its  use  as  an  inhala- 
tion, and  Sir  William  Lawrence  the  surgeon  employed 
it  with  some  success  alike  in  private  and  hospital  prac- 
tice.    Chloric  ether  was  also  used  at  St.  Bartholomew's 
and  the  Middlesex  Hospitals,  but  the  great  uncertainty 
of  its  action  and  the  expense  of  procuring  large  supplies 
effectually  prevented  chloric  ether  from  gaining  ground 
as    an    an  aesthetic.       Chloroform    was    experimental^ 
studied   by   Elourens   in    1847,  but   no    practical   uses 
were  made  of  his  work.     For   some  while   chloroform 
was  believed  to  be  a  "  safe  anaesthetic,"   an  impression 
to  which  the  language  of   Simpson's  pamphlet  rather 
lent  itself,  although  certainly  no   explicit  statement  to 
that   effect   can  be  found.     Unhappily  this   belief  re- 
ceived a   rude   shock  when   on   January  28th,  1848,  a 
death   from    chloroform  was  reported  at  a  place  near 
Newcastle-on-Tyne.       This    untoward   occurrence    was 
soon   followed  by  other   deaths,  and  men's  minds  be- 
came anxious.     At  this  pass   Snow,  with  that  earnest- 
ness and  acumen  which  characterised  all  he  undertook, 
commenced  his  researches  into  the  subject. 

In  1848,  Snow  published  his  "Experimental  papers 
on  narcotic  vapours." 


12  ANESTHETICS. 

-.Although  he  improved  upon  the  methods  in  vogue  for 
the  exhibition  of  ether  by  the  invention  of  his  inhaler, 
Snow  did  not  advocate  at  all  strongly  the  merits  of  that 
vapour  over  other  narcotics.  In  1847  he  perfected  his 
chloroform  inhaler,  being  actuated  by  the  belief  that 
this  anaesthetic  kills  through  being  used  in  too  con- 
centrated a  vapour.  Snow's  experience,  like  that  of 
most  others,  made  him  regard  chloroform  as  dangerous, 
and  so  in  1856  he  was  tempted  to  investigate  amylene, 
which  he  found  to  deserve  his  good  opinion.  A  Com- 
mittee appointed  by  the  Koyal  Medical  Chirurgical 
Society  of  Great  Britain  tendered  their  report  in  1864, 
which  strongly  insisted  upon  the  danger  of  chloroform 
and  the  inconvenience  of  ether  as  then  administered. 
Therein  were  embodied  many  suggestions,  some  of 
which  Clover,  who  had  then  achieved  a  high  reputation 
as  an  anaesthetist,  was  not  slow  in  carrying  to  a  prac- 
tical issue.  In  1862  he  had  constructed  and  published 
an  account  of  his  chloroform  apparatus  by  which  he 
regulated  the  percentage  of  vapour  administered. 
Pollock  and  Warrington  Haward  in  this  country  were 
keenly  alive  to  the  dangers  of  chloroform,  and  they  lost 
no  opportunity  of  urging  the  use  of  ether,  an  advocacy 
for  which  we  must  always  feel  grateful.  But  as  time 
went  on  Clover  was  less  and  less  inclined  to  use  chloro- 
form. For  minor  operations  he  found  nitrous  oxide 
gas  given  by  his  apparatus  to  answer  best,  and  he  was 
led  to  seek  some  means  of  prolonging  anaesthesia  so 
obtained.  This  he  achieved  by  the  employment  of 
gas  in  combination  with  ether,  for  which  he  soon  de- 
vised an  admirable  apparatus,  described  in  the  British 
Medical  Journal  in  1876.  Subsequently  his  portable 
regulating   ether   inhaler   was   introduced,  and  it  was 


HISTORICAL.  13 

mainly  by  the  compactness  and  efficiency  of  this  instru- 
ment that  the  practical  question,  how  to  give  ether 
rapidly  and  safely,  became  answered.  In  1879  the 
British  Medical  Association  undertook  to  re-investigate 
the  question  of  the  relative  safety  of  the  various  anaes- 
thetics, and  appointed  a  committee  to  carry  out  experi- 
ments. The  conclusions  to  which  this,  the  "  Glasgow 
Committee,"  arrived  were  in  favour  of  ether,  as  they 
found  chloroform  lowered  the  blood  tension  and  de- 
pressed the  action  of  the  heart.  In  1889  the  Nizam  of 
Hyderabad,  at  the  suggestion  of  Surgeon- Major  Laurie, 
granted  a  considerable  sum  of  money  to  re-investigate 
the  question,  and  the  first  Hyderabad  ComTnission, 
working  upon  small  mammals  in  India,  came  to  con- 
clusions more  favourable  to  chloroform.  As  these 
investigations  were  not  held  convincing  by  English 
experts,  a  second  Hyderabad  Commission,  in  which  Dr. 
Lauder  Brunton  assisted,  went  over  the  ground  again, 
and  corroborated  the  results  before  obtained.  These 
experiments  are  considered  at  length  in  the  chapter 
dealing  with  chloroform. 

It  is  undesirable  to  enter  further  into  detail.  The 
subsequent  history  of  anaesthetics  is  mainly  that  of 
attempts  to  introduce  fresh  substances  or  to  modify  the 
modes  of  administering  the  old  ones.  But  few  note- 
worthy advances  can  be  mentioned :  Snow,  Clover, 
Richardson,  in  this  country,  Claude  Bernard,  Paul 
Bert,  in  France,  with  others,  have  devoted  much  time 
and  labour  to  the  scientific  questions  connected  with 
anaesthesia,  but  any  account  of  such  labours,  to  be  in- 
telligible, would  occupy  more  space  than  can  here  be 
devoted  to  the  subject. 


14  ANESTHETICS. 


CHAPTEE   II. 

Preparation  of  a    Patient   and    Choice    of   an    Anaes- 
thetic. 

Although  the  anaesthetist  seldom  has  the  choice  of 
time  given  to  him,  the  selection  of  a  suitahle  hour  for 
the  operation  is  not  a  matter  of  indifference  in  adminis- 
tering an  anesthetic.  The  effect  of  anaesthetisation 
upon  the  robust  may  be  considered  trifling  and  transi- 
ent, yet  when  the  person  anaesthetised  is  an  invalid, 
and  either  weakly  or  highly  neurotic,  it  is  certainly  not 
so.  Individuals  are  more  liable  to  after-effects  of  an 
unpleasant  character  when  their  bodily  condition  is  one 
of  nervous  exhaustion  and  lowered  vitality.  It  is  then 
inadvisable,  unless  over-riding  circumstances  should 
exist,  to  give  an  anaesthetic  after  a  prolonged  fast — for 
instance,  in  the  early  morning  before  food  has  been 
taken.  Similarly,  it  is  inadvisable  to  select  an  ad- 
vanced hour  of  the  evening  when  the  body  will  be  spent 
with  a  day  of  activity  or  suffering.  Further,  an  anaes- 
thetic should  not  be  given  within  three  hours  after  a 
meal  of  solids,  as  a  full  stomach  impedes  the  produc- 
tion of  narcosis  and  leads  to  vomiting.  This  last 
occurring  during  partial  narcosis  may  occasion  fatal 
Lents  through  solids  being  drawn  into  the  trachea. 
It  is  well,  therefore,  to  select  the  period  of  greatest  vital 
activity,  and  this  is  found  in  most  persons  in  the  morn- 
ing or  early  afternoon.  Arrange  for  a  light  meal  of 
soft    and    easily   digested   matters    to   be   taken    three 


PEEPAEATION    OF    PATIENT.  15 

hours*  before  the  surgeon  should  arrive.  This  may 
consist  of  milk  foods,  strong  beef- tea,  or  jellies,  etc., 
varying  with  the  time  of  the  day  and  the  choice  of  the 
patient.  Weakly  persons  with  feeble  heart-action  will 
certainly  do  well  to  take  a  little  good  brandy  or  whisky 
(one  or  two  table-spoonfuls  in  an  equal  quantity  of  milk 
or  water)  half  an  hour  or  so  prior  to  the  operation, 
though  it  is  not  wise  to  make  the  administration  of 
stimulants  before  an  anesthetic  a  matter  of  routine. 
In  every  instance  it  is  recommended  that  the  bowels  be 
cleared  overnight  with  a  purge. 

The  following  is  a  condensed  form  of  a  useful  regimen 
to  be  adopted  at  the  time  of  an  operation  : — 
Operation  at  9  a.m. 

Beef-tea  or  thin  corn  flour  to  be  given  at  6  a.m. 
Operation  at  9  a.m.,  completed  by  10;  if  sickness 
occur  very  hot  water  may  be  given  in  sips  from  a 
feeder  or  porcelain  spoon.  At  2  p.m.  Brand's  or 
Edge's  essence  of  beef  in  jelly  ;  if  much  thirst  ice 
may  be  sucked,  or  iced  soda  and  milk  taken. 

If  very  prostrate  from  vomiting,  iced  brandy  and 
soda  water. 
At  6  p.m.  a  light  meal  of  fish. 
Operation  at  2  p.m. 

Breakfast  at  8,  tea,  coffee  or  cocoa,   bread  and 
milk,  fish,  no  meat. 

Beef- tea,  if  desired,  at  10.30. 
Operation  at  2,  over  at  3. 

Bread  and  milk  or  biscuit  and  tea  or  cocoa   at   7 
p.m. 

*  It  is  well,  unless  the  patient  be  in  a  very  feeble  state  of  health,  to 
adopt  Clover's  rale,  and  give  the  last  meal  five  or  six  hoars  before 
the  operation. 


16  ANAESTHETICS. 

"When  nitrous  oxide  alone  is  given,  these  elaborate 
details  maybe  omitted,  though  even  then  it  is  well,  with 
children  especially,  to  see  that  they  pass  water  before 
being  anaesthetised,  as  urination  is  often  performed 
unconsciously  whilst  under  the  influence  of  gas. 

A  patient  about  to  be  anaesthetised  should  be  placed 
in  the  recumbent  position,  excepting  cases  of  dental 
operations  under  nitrous  oxide.  The  clothing  should 
be  carefully  loosened,  corsets  quite  undone,  neck  bands 
left  open,  and  waist  belts  and  strings  removed.  It  is 
important  that  the  patient  be  as  comfortably  posed  as 
circumstances  will  permit,  for  while  tranquillity  of  mind 
and  body  go  far  to  assist  in  the  production  of  narcosis, 
anxiety  and  uneasiness  will  greatly  retard  its  accom- 
plishment. He  should  now  be  asked  to  open  his 
mouth,  and  a  quick  glance  given  to  ascertain  if  any 
artificial  dentures  or  an  obturator,  etc.,  be  worn. 
Such,  if  present,  must  be  removed  with  as  little  an- 
noyance to  the  patient  as  possible.  A  further  step  may 
be  taken  in  reassuring  him  by  a  few  cheery  words,  and 
if  necessary,  directions  as  to  how  he  is  to  take  the 
anaesthetic.  Such  instructions  are  often  of  real  service 
by  giving  him  something  about  which  to  think. 

When,  however,  the  anaesthetic  is  once  well  on  the 
way,  quietness  and  silence  must  be  maintained  ;  noise 
especially  in  the  case  of  nitrous  oxide — militates  con- 
siderably against  easy  and  tranquil  anaesthetisation. 

The  choice0  of  an  Anaesthetic  must  depend  on 

1.  The  condition  of  the  patient. 

2.  The  necessities  of  the  operation. 


*  The  question  with  whom  lies  the  choice  of  the  anaesthetic  is  con- 
sidered in  detail  in  Chapter  XII. 


PREPARATION    OF    PATIENT.  17 

Ether,  either  in  succession  to  nitrous  oxide  according 
to  Clover's  method,  or  given  by  itself,  is  the  best  and 
safest  anaesthetic  for  general  purposes,  and  should  be 
adopted  as  the  routine  method  of  producing  unconsci- 
ousness before  operations.  There  are,  however,  con- 
ditions which  are  often  held  as  justifying  a  deviation 
from  this  routine,  and  these  are  noticed  below.  It  may 
be  pointed  out,  however,  that,  although  apparently  a 
long  list,  these  conditions  really  represent  a  very  small 
minority  of  cases  when  compared  with  the  great  num- 
ber of  instances  in  which  ether  should  unhesitatingly 
be  adopted.  , 

Children. — Infants  and  young  children  bear 
chloroform  well,  and  resent  having  their  mouth  and 
nose  covered  by  a  face  piece,  an  objection,  although 
by  no  means  an  insuperable  one,  to  the  use  of  ether. 
In  many  instances  also  ether  produces  much  bronchial 
trouble,  so  that  a  better  anaesthetic  in  these  cases 
is  the  A.  C.  E.  mixture,  or  one  of  chloroform  and 
alcohol.  Children  about  five  or  six  years  of  age 
should  be  given  gas  and  ether,  unless  they  are 
notably  the  subjects  of  respiratory  trouble.  They 
will  probably  strongly  rebel  against  having  the  face 
piece  applied,  so  that  if  it  be  desirable  to  avoid 
"  a  scene,"  the  mixtures  of  chloroform,  alcohol,  and 
ether,  may  be  substituted  and  given  by  the  open 
method.  E  thy  dene  dichloride  is  advocated  for  chil- 
dren by  some,  but  experience  proves  that  it  is  not 
taken  more  readily  and  does  not  appear  to  be  in  any 
way  safer  in  its  action  than  chloroform.  Although  the 
use  of  chloroform  is  unquestionably  attended  with 
happy  results  in  the  case  of  children,  it  must  be  remem- 
bered that  deaths  from  this  agent  are  by  no  means  con- 

c 


18  ANESTHETICS. 

fined  to  adults.  It  cannot,  therefore,  be  too  strongly 
impressed  upon  the  mind  that  children  run  a  risk,  and 
probably  as  great  a  risk,  in  chloroform  narcosis  as  do 
adults. 

Pulmonary  Disease. — Persons  of  early  adult 
and  adult  life  should  have  ether  given  to  them, 
provided  always  they  are  free  from  pronounced  pul- 
monary affections  and  renal  diseases.  With  regard 
to  asthmatics,  and  those  suffering  from  chronic 
cough,  dyspnoea,  or  emphysema,  the  A.  C.  E.  mix- 
ture should  be  tried,  but  if  the  ether  in  this  still 
gives  distress,  its  quantity  may  be  decreased,  or  the 
Vienna  compound  used  instead.  And  should  the  pati- 
ent suffer  greatly  from  the  exclusion  of  air,  through  the 
employment  of  an  inhaler,  chloroform  can  be  given  by 
the  open  method,  as  that  substance  will  not  only  pro- 
duce anaesthesia  but  will  obviate  asthmatic  seizures. 
For  the  subject  of  chronic  bronchial  disease  the  choice 
of  an  anaesthetic  should  be  made  solely  by  consideration 
of  his  symptoms.  In  the  presence  of  much  dyspnoea, 
diluted  chloroform  will  be  found  far  preferable  to  ether. 
Emphysematous  individuals  with  large  (bullock's) 
hearts  are  always  anxious  cases  requiring  great  nicety 
of  treatment.  On  the  one  hand  lies  the  possible  dan- 
ger of  ether  producing  a  water- logged  condition  of  the 
rigid  chest,  and  on  the  other  a  more  than  probable 
danger  of  syncope  through  the  depressant  action  of 
chloroform  on  the  enfeebled,  dilated  heart.  In  this 
dilemma  I  have  found  the  A.  C.  E.  mixture  to  answer 
well,  though  it  needs  careful  watching,  as  many  and 
grave  symptoms  may  occur  during  its  use.  Among 
persons  who  have  but  one  available  working  lung — as 
when  the  other  is  bound  by  pleuritic  adhesions  subse- 


PREPARATION    OF    PATIENT.  19 

quent  to  effusion,  or  when  one  is  compressed  by  an 
effusion  or  empyema — the  choice  of  an  anaesthetic  be- 
comes one  of  difficulty.  In  such  cases  ether  is  badly 
borne,  and  chloroform  diluted  with  alcohol  is  preferable. 
And  again,  the  heart,  in  these  cases  being  often  so 
pressed  upon  or  displaced,  is  intolerant  of  further  de- 
pressing effects  ;*  hence  extreme  caution  will  be  found 
necessary. 

Renal  Disease. — Where  the  kidneys  are  much 
damaged  and  there  is  considerable  danger  of  suppression 
of  urine,  ether  is  by  many  held  to  be  contra- indicated. 
Certainly  in  many  instances  no  such  untoward  result 
has  been  brought  about ;  still,  perhaps  it  is  well  to  sub- 
stitute the  A.  C.  E.  mixture  for  ether,  for  those  patients 
who  are  the  subjects  of  pronounced  renal  disease. 

Arterial  disease,  if  present  in  any  grave  degree, 
whether  fibroid  or  due  to  senile  change  when  far  ad- 
vanced, is  a  contra-indication  for  the  giving  of  pure 
ether.  The  blood  pressure  would  be  increased  by  this 
substance,  the  heart's  work  augmented,  and  consider- 
able strain  imposed  upon  the  diseased  arterial  walls  by 
which  they  become  in  danger  of  rupture — a  result 
liable  to  occur  in  the  brain  and  leading  there  to  the 
gravest  consequences. 

For  the  aged,  that  is  for  those  over  60  years  of  age, 
chloroform  is  commonly  held  to  be  preferable  to  ether 
and  in  many  instances  this  is  true.  It  is,  however, 
true  only  because  persons  past  middle  life  are  often  the 
subjects  of  chronic  bronchial  trouble ;  they  are  also  fre- 
quently diseased  in  their  vascular  systems,  and  upon 

*  Any  sudden  change  in  the  posture  of  the  patient  is  dangerous 
and  must  be  avoided.  On  this  subject  see  the  article  on  etherisation 
by  the  rectum  Chapter  IV. 

c  2 


20  ANESTHETICS. 

that  account  liable  to  be  injuriously  affected  by  ether. 
Old  persons  too,  like  infants,  are  susceptible  to  a  bron- 
chial and  laryngeal  irritability  which  ether  excites, 
producing  in  some  distressing  cough,  dyspnoea,  and 
exhaustion.  However,  for  aged  and  feeble  subjects 
with  weak  hearts  and  depressed  vitality,  ether,  notwith- 
standing the  drawbacks  alluded  to  above,  is  beyond 
doubt  the  best  anaesthetic. 

In  conditions  of  collapse,  e.g.,  railway  smashes,  guu- 
shot  wounds,  strangulated  hernia?,  ruptured  viscera,  or 
conditions  when  the  vitality  has  sunk  very  low,  as  in 
the  case  of  carcinoma  affecting  the  oesophagus,  pylorus, 
and  causing  chronic  starvation  ;  also  in  collapse  due  to 
severe  hemorrhages  or  other  causes,  or  provoked 
by  high  temperatures,  it  may  be  necessary  to  i)er- 
form  an  operation^  and  it  will  usually  be  desirable  to 
administer  an  anesthetic.  Ether  if  properly  adminis- 
tered is,  I  am  sure,  the  best  and  safest  anaesthetic  for 
these  cases.  It  should  be  given  from  a  Clover's  inhaler 
as  when  that  apparatus  is  properly  handled  there  need 
be  no  dyspnoea  or  impediment  to  respiration.  Very 
little  anaesthetic  is  required,  and  the  mask  may  be 
taken  off  during  inspiration  every  three  or  four  respira- 
tions. When  there  is  very  considerable  respiratory 
trouble  complicating  the  case,  the  A.  C.  E.  mixture 
may  be  substituted  for  ether  and  given  either  by  means 
of  an  Allis'  inhaler,  a  cone,  or  upon  lint.  Still,  ether  is 
par  excellence  the  anaesthetic,  as  it  not  only  produces 
narcosis,  but  stimulates  the  heart  and  aids  the  circula- 
tion. 

In  Moici5i;s  cordis. — It  often  becomes  a  question  as  to 
what  anesthetic  should  be  employed  in  cases  of  organic 
heart  disease.     To  answer  this  question  we  have  to  con- 


PREPARATION    OF    PATIENT.  21 

sider  firstly,  the  various  forms  of  valvular  disease,  and 
secondly,  the  conditions  of  hypertrophy,  atrophy,  and 
muscular  degeneration,  as  well  as  the  pericardial  condi- 
tions which  interfere  with  cardiac  function. 

Valvular  disease  of  the  heart,  except  when  incom- 
petency at  the  aortic  orifice  occurs,  does  not,  per  se, 
greatly  affect  the  prognosis  about  the  safety  or  danger 
of  giving  an  anaesthetic,  although  the  changes  brought 
about  in  the  vessels,  tissues,  and  organs  of  the  body  in 
general  through  such  lesions  will  possibly  do  so.  In- 
deed, it  is  a  fact  that  in  but  few  cases  of  deaths  from  an 
anaesthetic  have  the  valves  of  the  heart  been  found  dis- 
eased at  the  necropsy. 

Degenerations  of  the  myocardium. — When  the  heart 
muscle  has  undergone  structural  changes,  the  danger  in 
producing  anaesthesia  is  greatly  increased.  Any  altera- 
tion in  the  respiratory  or  vascular  systems  induced  by 
anaesthetics  imposes  an  extra  strain  upon  the  already 
weakened  and  diseased  heart — one  which  it  is  unable 
to  sustain ;  hence  supervenes  syncope.  When  the 
heart  trouble  is  not  complicated  by  pulmonary  engorge- 
ment, oedema  or  hydrothorax, — is  in  short  largely  com- 
pensated,— ether  should  be  given  and  a  Clover's  inhaler 
employed.  It  has  been  suggested  that  a  cone  or  towel 
is  safer  in  these  cases,  but  I  cannot  think  this  to  be  the 
case,  since  with  a  Clover's  inhaler  you  can,  by  fre- 
quently removing  the  mask  or  refilling  the  inhaler  bag, 
give  any  degree  of  dilution  of  ether  you  require. 

When  pronounced  pulmonary  trouble  exists  and 
ether  cannot  be  borne,  the  A.  C.  E.  mixture  should  be 
given.  Should  nitrous  oxide  be  administered  in  morbus 
cordis  ?  I  think  yes,  but  if  the  case  is  one  of  advanced 
disease  and  the  organ  is  working  feebly,  it  is  wise  to 


22  ANESTHETICS. 

supplement  the  nitrons  oxide  by  allowing  it  to  pass 
over  ether-vapour.  This  plan  has  in  my  hands 
answered  most  admirably.  Chloroform,  whether  pure 
or  diluted,  cannot  be  given  to  persons  having  diseased 
hearts  without  increasing  the  risk  of  syncope,  which 
under  any  circumstances  the)'  must  run. 

Hypertrophied  hearts  are  in  practice  usually  dilated 
hearts,  and  being  so  are  muscularly  at  a  disadvantage. 
The  same  rules  given  for  guidance  above  will  serve 
here. 

Some  highly  nervous,  excitable  persons  are  much 
terrified  by  the  application  of  a  face  piece,  and  indeed 
in  some  few  cases  the  mental  distress  and  terror  thus 
excited  may  be  sufficient  to  occasion  serious  indisposi- 
tion. In  cases  such  as  these  it  is  especially  useful  to 
employ  the  A.  G.  E.  mixture  upon  lint,  replacing  it  by 
ether  from  Clover's  inhaler  so  soon  as  the  patient  is 
sufficiently  dazed  as  not  to  perceive  the  alteration. 

Pregnant  women  take  all  forms  of  anaesthetics 
well,  but  if  excitable  and  nervous  as  they  are  apt  to  be, 
it  is  better  to  avoid  the  coughing  and  straining  which 
may  follow  the  employment  of  ether.  It  will  be  found, 
however,  that  unless  very  nervous,  women  in  this  con- 
dition take  nitrous  oxide  followed  by  ether  well— nor 
are  they  more  liable  to  after  trouble  than  at  other 
times — in  all  such  instances,  as  little  of  the  anaesthetic 
should  be  given  as  is  consistent  with  true  anaesthesia, 
since  it  is  manifestly  important  to  avoid  vomiting. 

From  the  surgeon's  point  of  view — to  decide  upon  the 
choice  of  an  anaesthetic  is  difficult,  as  it  is  impossible 
to  lay  down  hard  and  fast  rules  where  there  will  be 
always  conflicting  considerations. 


OPERATIONS.  23 


Operations  about  the  Head,  Face,  Trachea  and 
Eespiratory  Tract. 

Brief    operations    about     the     mouth,    nose,    or 

pharynx,  such  as  the  extraction  of  teeth,  excision  of 
tonsils,  opening  of  abscesses,  tearing  off  mucous  polypi, 
etc.,  can  often  be  performed  under  nitrous  oxide.  With 
this  agent  from  *5  to  1  minute  of  unconsciousness  can  be 
expected.  If  the  operation  is  likely  to  occupy  more 
than  this  time,  and  if  the  cautery  is  not  to  be  used,  gas 
with  ether  should  be  employed,  as  this  combination  will 
prolong  anaesthesia.  In  operations  accompanied  by 
severe  haemorrhage,  but  which  do  not  need  much  time, 
the  gas  and  ether  mixture  possesses  an  advantage,  inas- 
much as  the  patient  rapidly  resumes  consciousness,  and 
so  the  danger  of  blood  being  drawn  through  the  trachea 
into  the  respiratory  tract  will  be  avoided.  In  operations 
for  the  removal  of  post-nasal  adenoid  growths,  I 
have  for  some  years  extensively  used  gas  and  ether  with 
success.  Some  specialists  prefer  chloroform  for  such 
cases  (i.)  because  a  more  profound  and  lasting  anaesthesia 
is  thus  obtained,  (ii.)  because  less  violent  bleeding  takes 
place  at  the  time  of  the  operation.  On  the  other  hand, 
the  rapid  resumption  of  consciousness  under  ether  cer- 
tainly minimises  the  danger  of  blood  entering  the  lungs. 
When  the  operation  is  likely  to  prove  a  prolonged  one, 
chloroform  will  be  more  satisfactory  to  the  operator. 

Staphyloraphy  necessitates  the  mouth  being  open, 
and  it  is  a  matter  of  consideration  that  the  operator 
should  have  free  and  uninterrupted  access  to  the  buccal 
cavity.  To  effect  this,  the  patient  can  be  put  under  the 
influence  of  chloroform  and  maintained  so  by  anaesthe- 


24  ANESTHETICS. 

tising  through  the  nostril  (as  described  in  Chap.  V.). 
The  same  procedure  answers  for  operations  about  the 
tongue.     (See  also  Chap.  IV). 

Removal  of  the  upper  or  lower  jaw  should 
be  performed  under  chloroform,  as  the  cautery  is  often 
requisite  and  the  use  of  a  face  piece  impossible.  In 
extensive  removals  of  growths  about  the  jaws,  it  is  fre- 
quently advisable  to  perform  a  preliminary  tracheotomy, 
and  then  give  the  anaesthetic  through  a  Trendelenburg's 
tube,  at  the  same  time  plugging  the  pharynx. 

Operations  upon  the  larynx,  e.g.,  thyrotomy,  will  re- 
quire a  preliminary  tracheotomy,  and  in  these  cases  I 
prefer  to  keep  up  the  anaesthesia  by  a  Junker's  inhaler 
to  the  afferent  tube  of  which  is  fixed  a  catheter.  By 
this  means  the  amount  of  chloroform  given  can  be 
more  safely  adjusted  than  when  a  Halm's  tube  and 
funnel  are  employed.  In  all  the  above  mentioned  cases 
in  which  chloroform  is  mentioned  as  being  more  con- 
venient an  alternative  method  exists,  namely,  rectal 
etherisation. 

Operations  about  the  eyes  require  extreme  narcosis, 
absolute  immobility  and  freedom  from  coughing  being 
essential.  Nitrons  oxide  and  ether,  provided  the  ether 
be  pushed  very  far,  answer  well ;  there  is  of  course  the 
possibility  of  ether  exciting  a  fit  of  coughing,  which, 
should  the  case  be  one  of  excision  of  a  cataract,  and 
should  a  preliminary  iridectomy  have  been  already 
done,  may  lead  to  forcible  extrusion  of  the  vitreous. 
But  this  can  only  arise  when  the  patient  is  not  suffici- 
ently under  the  anaesthetic.  There  is  less  fear  of 
coughing  with  the  use  of  the  A.  C.  E.  mixture. 

In  excision  of  the  eyeball,  where  coughing  is  not  of 
such  moment,  ether  may  be  used,  and  should  be  pushed 


ABDOMINAL    SURGERY.  25 

to  deep  narcosis  before  proceeding  with  an  operation. 
For  passing  probes  or  slitting  lip  the  lacrimal  canals, 
gas  is  not  satisfactory,  as  the  jactitation  interferes  with 
the  operator;  here  the  use  of  gas  and  ether  answers 
every  purpose  by  obviating  involuntary  movements. 

For  operations  about  the  thorax,  a  mixture  (A.  C.  E.) 
is  usually  more  advantageous  than  chloroform  or  ether 
when  given  alone,  so  that  where  there  is  especial  reason 
for  fearing  the  respiratory  difficulty  of  ether,  this  agent 
should  be  substituted.  For  tapping  in  cases  of  pleuritic 
effusion,  gas  is  sufficient.  Chloroform  in  cases  of 
empyema  seems  peculiarly  liable  to  dangerous  results, 
the  heart  is  usually  hampered  and  respiration  abnor- 
mally performed  ;  several  deaths  have  resulted  from 
chloroform  given  in  such  cases. 

It  is  in  these  operations  that  rectal  etherisation  seems 
likely  to  be  of  very  great  service.  (See  Etherisation  by 
the  Rectum). 

Abdominal  Surgery. 

In  dissecting  operations,  when  tranquillity  of  respira- 
tion is  desired,  as  in  operating  for  the  radical  cure  of 
hernia  in  young  children,  a  mixture,  methylene,  A.  C.  E., 
&c,  must  be  employed  instead  of  ether,  but  for  all 
prolonged  and  exhausting  operations  ether  should  be 
given  unless  strongly  contra-indicated.  Thus  I  have 
found  for  caesarian  sections,  ovariotomies,  hysterec- 
tomies and  ablation  of  the  kidney,  ether  if  carefully 
given  answers  very  well. 

In  Labour. 

There  is  a  consensus  of  opinion  in  favour  of  chloro- 
form in  these  cases,  based  partly  upon  the  assumption 


26  ANESTHETICS. 

that  this  agent  is  comparatively  safe  for  parturients, 
and  partly  upon  the  more  agreeable  character  of  the 
substance.  This  assumption,  however,  is  open  to  doubt, 
for  chloroform  cannot  be  in  any  way  deemed  freer 
from  danger  in  childbirth  than  at  any  other  time.  If 
chloroform  be  employed  it  should  not  be  entrusted  to 
the  hands  of  a  nurse  or  other  person  unless  skilled  in 
its  use.  The  various  mixtures  answer  well  in  assuaging 
the  pangs  of  childbed,  and  are  probably  safer  than 
chloroform.  Ether,  though  advocated  by  some,  is  dis- 
advantageous in  these  cases,  as  it  may  provoke  strain- 
ing, coughing,  sickness,  and  headache,0  but  for  general 
obstetric  operations,  and  especially  where  the  patient  is 
exhausted  and  needs  stimulating,  ether  may  be  usefully 
employed.  In  short  it  may  be  said  that  chloroform  or 
the  A.  C.  E.  mixture  may  be  employed  as  an  anodyne 
in  labour,  ether  when  surgical  anaesthesia  is  necessary. 

*  In  my  private  practice  I  have  met  with  cases  of  women  who  after 
trying'  chloroform  preferred  to  take  ether  in  their  confinements,  stat- 
ing that  it  produced  more  exhilaration  and  general  feeling  of  well- 
being,  while  it  assuaged  their  pangs  more  efficiently  than  chloroform. 


NITROUS    OXIDE    GAS.  27 


CHAPTEE   III. 

Niteous  Oxide  Gas — Laughing  Gas  or  Simply  "Gas." 

Chemical  and  Physical  Properties. — Nitrous  Oxide 
Gas  [N20]  is  a  colourless  body  almost  devoid  of 
odour.  It  possesses  a  neutral  reaction  and  consists  of 
nitrogen  and  oxygen  in  chemical  union,  thus  differ- 
ing from  the  air,  which  is  composed  of  these  gases  in 
mechanical  mixture.  Nitrous  oxide  gas  possesses  well- 
defined  anaesthetic  properties,  which  appear  to  be  quite 
distinct  from  the  asphyxial  symptoms  frequently  ac- 
companying its  administration.  This  gas  agrees  with 
oxygen  in  many  of  its  chemical  properties ;  thus,  it  sup- 
ports combustion  when  ignited  bodies  are  plunged  into 
it.  At  a  pressure  of  fifty  atmospheres  and  a  tempera- 
ture of  44*6°  F.  (7°  C),  it  becomes  liquefied,  and  ad- 
vantage is  taken  of  this  to  enable  the  gas  to  be  carried 
about  in  iron  or  steel  bottles,  these  latter  occupying  less 
space. 

Nitrous  oxide  is  decomposed  at  a  red  heat,  but  shows 
no  tendency  to  undergo  change  at  lower  levels  of  tem- 
perature. Cold  water  dissolves  more  than  its  own 
volume  of  this  gas,  while  hot  water  dissolves  less,  hence 
it  is  advantageous  to  collect  it  over  water  at  15°  C. 
Alcohol  takes  it  up  in  a  still  larger  proportion. 

Preparation.  —  Granulated  nitrate  of  ammonia  is 
pounded  to  ensure  its  being  finely  divided,  and  is 
placed  in  a  strong  glass  retort.  The  capacity  of  the 
generator  should  be  one  pint  to  allow  of  safe  decomposi- 


28 


ANESTHETICS. 


tion  of  three -quarters  of  a  pound  of  uitrate  of  ammonia, 
one  quart  for  that  of  two  pounds.  One  pound  of  the 
salt  will  make  thirty  gallons  of  nitrous  oxide  gas.  The 
generator  is  then  carefully  heated  in  a  sand  bath  or 
over  a  bun  sen,  after  being  connected  by  tubing  with 
wash  bottles  of  at  least  the  capacity  of  a  quart,  as  indi- 
cated in  the  figure.  At  2263  F.  the  salt  melts ;  at  460°  F. 
it  gives  off  gas,  and  the  temperature  must  not  exceed 
this  by  many  degrees,  otherwise  nitric  oxide  will  come 
over,    contaminating  the  laughing  gas.      The  nitrous 


Frc  1. — Apparatus  for  the  preparation  of  Nitrous  Oxide  Gas. 
a.  Generator,  b.  Bunsen's  burner.  1  to  4.  Wash  bottles,  c.  Delivery 
tube  to  be  connected  with  a  reservoir  for  storing  the  gas. 


oxide  should  bubble  over,  not  boil  over,  not  more  than 
thirty  gallons  being  allowed  to  volatilise  in  an  hour. 
It  is  well  to  have  a  self-regulating  gas  jet,  which  is 
lowered  as  the  temperature  rises  too  much  and  viae 
versa.  Bottle  no.  1  nearest  the  retort,  which  may  with 
advantage  be  placed  in  cold  water,  answers  the  pur- 
pose of  catching  the  drippings  which  come  over  from 
the  generator ;  it  contains  clean  cold  water  almost  up 
to  the  lower  end  of  the  long  tube.      This  tube  is  per- 


NITROUS    OXIDE    GAS.  29 

foratod  in  order  to  break  up  the  gas  as  it  jmsses  over, 
and  to  ensure  its  being  washed  out  thoroughly.  In 
bottle  no.  2  about  four  ounces  of  ferrous  sulphate  are 
placed,  and  water  to  a  few  inches  added.  Bottle  no.  3 
contains  a  stick  of  potash,  and  water  also  added.  It 
is  sometimes  advisable  to  use  an  additional  bottle  or 
two  containing  simply  water  for  washing  the  gas  fur- 
ther. Having  traversed  these  bottles  the  gas  is  received 
into  the  gasometer,  which  should  have  a  capacity  of 
30  or  40  gallons.  When  nitrous  oxide  is  stored  in 
bottles,  special  apparatus  will  be  needed  to  force  the 
gas  in  under  the  pressure  of  fifty  atmospheres. 

The  impurities  to  which  nitrous  oxide  is  liable  are : — 

Sulphates. 

Chlorides. 

Other  oxides  of  nitrogen,  which  produce  coughing  and 
feeling  of  suffocation. 

Oil  (from  lubrication  of  apparatus)  which  gives  a 
rancid  nauseous  smell  to  the  gas. 

To  test  for  these  impurities,  let  the  gas  bubble 
through  solutions  of  barium  chloride,  which  will  precipi- 
tate sulphates,  and  through  solutions  of  nitrate  of  silver, 
which  will  precipitate  chlorides,  while  the  other  adul- 
terations will  be  detected  by  the  nose. 

Purification  of  nitrous  oxide  is  of  undoubted  import- 
ance, as  was  shown  in  the  earlier  days  of  anaesthesia, 
when  the  most  bizarre  symptoms  were  constantly  aris- 
ing, many,  if  not  all  of  which,  were  traceable  to  foreign 
products  being  contained  in  the  gas  employed. 

Some  persons  prefer  the  freshly  prepared  gas,  but 
liquefied  gas  stored  in  bottles  gives  results  practically 
as  good. 


30  ANAESTHETICS. 


Physiological    Action  of    Nitrous  Oxide — The  Vege- 
table Kingdom. 

It  appears  to  suspend  rather  than  extinguish  vitality. 
Seeds  will  not  germinate  but  remain  uninjured  when 
kept  in  it  an  indefinite  period.  Seeds,  if  sprouting, 
cease  to  develop  when  placed  in  an  atmosphere  of 
this  gas,  but  resume  their  growth  when  again  placed  in 
the  air.  Jolyet  and  Blanche  found  that  plants  placed 
in  nitrous  oxide  gas  cease  to  absorb  carbonic  dioxide, 
and  do  not  increase  in  size.  When  oxygen  is  allowed 
to  mix  with  the  nitrous  oxide  the  seeds  germinate,  and 
the  plants  grow. 

The  Animal   Kingdom. 

Cold-blooded  animals  die  in  an  atmosphere  of  nitrous 
oxide  in  two  hours.  This  contrasts  with  what  ob- 
tains when  the  same  creatures  are  placed  in  indif- 
ferent gases,  such  as  hydrogen  or  nitrogen,  for  under 
these  circumstances  death  does  not  occur  for  three 
hours  and  is  preceded  by  stupor  but  not  true  analgesia. 
Kappeler  has  shown  that  frogs  placed  in  it  lose  reflexes 
after  a  very  few  minutes,  whereas  the  reflexes  persist 
for  several  hours  when  the  frogs  are  placed  in  an  in- 
different gas,  e.g.,  nitrogen  (Goldstein).  Sir  Humphry 
Davy,  in  his  careful  research,  showed  that  small  mam- 
mals and  birds  soon  die  in  it,  although  when  it  is 
mixed  with  oxygen  they  live  until  the  oxygen  tension 
sinks  to  6  per  cent.,  as  a gainst  a  carbonic  dioxide  ten- 
sion of  12  per  cent.  Exposed  to  such  measures  the 
animals  remain  sensitive  to  the  last,  and  it  may  be 


PHYSIOLOGICAL    ACTION    OF    NITROUS    OXIDE.  31 

stated  generally  that  mixtures  of  nitrous  oxide  with 
other  gases  under  normal  pressure  are  useless  for 
anaesthetic  purposes. 

Animals  placed  in  non-respirable  indifferent  gases 
become  convulsed  before  death  ;  this  does  not  obtain 
when  they  are  made  to  respire  nitrous  oxide.  Their 
respirations  simply  grow  more  and  more  shallow,  and 
finally  cease  without  any  of  that  besom  de  respirer  which 
is  elicited  when  simple  deprivation  of  oxygen  is  prac- 
tised. 

Krishaber  experimenting  with  rabbits  found  a  marked 
acceleration  of  the  rate  of  the  pulse,  with  increased 
force  at  first  in  the  heart  beat.  Subsequently  where 
anaesthesia  was  determined  some  retardation  occurred, 
while  the  cardiac  rhythm  became  less  regular.  Ee- 
spiration  was  accelerated  and  death  resulted  in  two  or 
three  minutes.  He  performed  control  experiments  by 
ligaturing  the  trachea.  In  these  cardiac  rhythm  re- 
mained unchanged  until  after  the  fourth  minute,  when 
the  heart  beats  grew  irregular,  and  ceased  at  times 
varying  from  seven  to  eleven  minutes.  The  animals 
remained  sentient  to  the  very  last.  I  have  repeated 
these  experiments,  using  dogs  and  cats  in  preference 
to  rabbits  because  these  last  are  peculiarly  liable  to 
fright,  and  this  disturbs  the  rhythm  alike  of  the  heart 
and  respiration,  and  in  the  main  my  results  agree  with 
Krishaber's.  While  dogs  die  in  from  two  to  three 
minutes  in  nitrous  oxide,  they  do  not  succumb  to  as- 
phyxia for  five  ;  under  nitrous  oxide  they  grow  wholly 
insentient  in  from  fifteen  to  thirty  seconds,  while  in 
asphyxia  consciousness  to  pain  only  ceases  with  life. 
Under  nitrous  oxide  I  found  the  heart  little  affected 
until  the  respiration  was  gravely  interfered  with,  and 


32  ANESTHETICS. 

then  it  gradually  failed  before  totally  stopping.  The 
creatures  seemed  under  the  gas  to  sink  to  sleep,  and 
from  sleep  to  pass  into  death,  while  when  asphyxiated 
they  struggled  from  first  to  last. 


In  the  Human  Subject. 

It  is  probable  that  this  gas  when  administered  pure, 
and  not  mixed  with  oxygen,  enters  the  blood  by  diffus- 
ing through  the  thin  walls  of  the  air-cells  in  the  lungs. 
In  the  blood,  a  small  quantity  is  dissolved,  but  the  bulk 
is  connected  in  some  loose  way  with  the  blood  constitu- 
ents, probably  being  associated  more  or  less  closely 
with  the  albumins  and  albuminoids  of  the  liquor  san- 
guinis and  corpuscles.  According  to  Hermann  nitrons 
oxide  destroys  the  red  blood  corpuscles.  The  effect  of 
shaking  arterial  blood  with  nitrous  oxide  gas  is  to 
darken  it,  showing  that  nitrous  oxide  gas  is  able  to 
displace  oxygen.  But  whatever  union  does  take  place 
is  very  unstable,  as  blood  parts  at  once  with  its  nitrous 
oxide  when  left  in  free  contact  with  oxygen  or  air. 

Under  nitrous  oxide,  the  respiration  becomes  slowed 
and  shallow,  and,  if  the  gas  be  pushed,  a  complete  ces- 
sation of  respiratory  movements  eventually  takes  place. 
The  amount  of  tissue  change  occurring  in  nitrous  oxide 
narcosis  is  lessened,  and  so  the  quantity  of  carbonic 
dioxide  which  the  lungs  give  off  is  diminished.  Sub- 
sequently to  the  administration,  the  exhalation  of  car- 
bonic dioxide  is  increased.  The  heart  beats  quietly, 
fully  and  regularly  under  this  gas,  the  pulsations  are 
somewhat  slowed  in  profound  narcosis.  There  is, 
however,  but  very  slight  danger  of  heart  failure  result- 


PHYSIOLOGICAL    ACTION    OF    NITROUS    OXIDE.  66 

ing  from  inhalation.  In  animals  killed  by  nitrous 
oxide  gas  the  heart  goes  on  beating  even  after  the 
respirations  have  quite  stopped.  It  is  therefore  less 
important  to  watch  the  pulse  than  the  respiration. 
Blood-pressure  is  somewhat  lowered  except  in  the  brain 
and  cord,  the  vaso- motor  system  of  different  areas 
being,  it  would  appear,  diversely  affected.  This  lessened 
pressure  is,  however,  but  slight. 

In  some  observations  I  made  upon  this  subject,  I 
found  that  while  asphyxia  caused  diminution  of  the 
bulk  of  the  brain  and  cord,  nitrous  oxide  produces  so 
great  an  enlargement  as  to  force  out  the  cerebro- spinal 
fluid.  There  can  be  no  doubt  these  changes  are  vaso- 
motor in  origin,  and  explain  many  of  the  nervous 
phenomena  elicited  in  persons  narcotised  by  nitrous 
oxide.  The  great  distension  of  the  vessels  must  press 
upon  the  nerve-cells  and  fibres  both  of  the  brain  and 
cord,  and  so  interfere  with  their  function.  (Physiologi- 
cal Action  of  Nitrous  Oxide,  Transactions  of  Odontoloyi- 
cal  Society,  vols,  xviii.  and  xix.). 

In  a  recent  essay,  Dr.  George  Johnson  has  sought  to 
establish  the  contention  that  nitrous  oxide  acts  wholly 
or  mainly  as  an  asphyxiant.  The  experiments  upon 
which  he  bases  his  belief,  however,  appear  to  have  been 
made  without  due  care  being  taken  to  eliminate  con- 
current asphyxia.  His  statement  that  the  pulse  under 
nitrous  oxide  is  diminished,  and  even  becomes  imper- 
ceptible, is  utterly  opposed  to  my  experience.  Since 
nitrous  oxide  has  to  be  given  under  ordinary  circum- 
stances without  access  of  air  or  oxygen,  asphyxial  sym- 
ptoms will  eventually  supervene,  but  these  come  on 
subsequently  to  true  anesthesia  and  need  never  be  pro- 
duced.    The  peculiar  muscular  effects  of  nitrous  oxide 

D 


34  ANESTHETICS. 

gas  which  constitute  "jactitations  "  are  very  different 
irom  an  epileptiform  convulsion  to  which  this  writer  has 
compared  them.  In  cases  of  true  epileptics  to  whom 
I  have  given  nitrous  oxide,  jactitations  have  assumed 
their  normal  form,  and  sometimes  a  regular  epileptic  fit 
has  occurred  subsequently  to  the  recovery  of  conscious- 
ness. It  would  seem  reasonable  to  suppose  that,  were 
the  nitrous  oxide  anaesthesia  a  simple  asphyxial  state 
culminating  in  an  epileptiform  fit,  in  the  cases  to 
which  I  have  just  referred,  the  epileptic  fit  should  follow 
directly  or  even  replace  the  jactitation.  Again,  in  per- 
sons who  take  nitrous  oxide  together  with  oxygen  either 
simply  or  under  pressure  (Paul  Bert),  no  asphyxial 
symptoms  develop,  and  yet  a  more  or  less  complete 
anaesthesia  is  attained. 

The  senses  of  a  person  passing  under  nitrous  oxide 
are  at  first  rendered  somewhat  more  acute,  after  which 
follows  a  condition  of  analgesia.  During  the  first  stage 
of  unconsciousness,  a  loose  tooth  may  be  extracted 
without  pain,  although  the  patient  has  a  vague  idea 
that  something  is  being  done.  A  few  seconds  later, 
and  the  individual  is  profoundly  unconscious  and  insen- 
sitive to  all  his  external  surroundings.  Irregular  dis- 
charges of  nervous  energy  frequently  show  themselves 
at  this  stage  in  jactitations  of  the  arms  and  legs.  If 
the  gas  continues  to  be  respired,  the  limbs  become  rigid, 
the  rigidity  being  every  second  or  two  broken  by  a 
sudden  contraction  of  the  flexors.  Rhythmic  tremors 
of  hands  and  arms  are  occasionally  elicited.  More 
rarely  the  whole  body  of  the  patient  arches  forward  like 
a  bow  (opisthotonos)  jerking  him  out  of  the  chair.  This 
condition  is  especially  liable  to  occur  in  children.  The 
muscles  soon  relax  and  remain  flaccid.      The  degree  of 


PHYSIOLOGICAL    ACTION    OF    NITROUS    OXIDE.  35 

rigidity  and  the  amount  of  jactitation  vary  in  different 
cases;  children  show  jactitation  early,  and  the  move- 
ments of  the  limbs  are  more  marked  in  them  than  in 
adults.  The  superficial  reflexes  are  abolished,  that  of 
the  patella  tendon,  however,  persists ;  and  in  many 
cases  ankle  clonus  is  developed  under  nitrous  oxide.0 
The  pupil  usually  undergoes  wide  dilatation  when  com- 
plete anaesthesia  is  attained,  however  this  phenomenon 
is  not  absolutely  constant  and  cannot  be  taken  as  an 
indication  of  danger. 

During  the  condition  of  hyperesthesia  which  pre- 
cedes anaesthesia,  the  subject  is  often  affected  by  hallu- 
cinations, frequently  of  an  erotic  nature,  and  the  im- 
pressions then  received  remain  firmly  imprinted  upon 
the  brain.  The  difficulty  of  convincing  persons  that 
such  impressions  are  not  realities  should  lead  every 
•administrator  to  secure  independent  evidence  of  his 
actions  while  his  patient  is  unconscious.  The  bladder 
and  even  the  rectum  may  be  involuntarily  emptied 
under  nitrous  oxide,  and  hence  it  is  always  wiser  to 
allow  patients  to  pass  urine  beforehand.  As  a  rule  the 
alimentary  tract  is  unaffected  by  nitrous  oxide,  and 
nausea,  vomiting,  and  bilious  derangement,  rarely  occur 
after  its  administration.  However,  some  persons 
through  nervousness  swallow  the  gas,  and  this  causing 
distension  of  the  stomach  may  give  rise  to  a  reflex 
vomiting.  In  view  of  the  possible  occurrence  of  this 
trouble,  it  is  well  for  patients  to  abstain  from  food 
immediately  before  taking  nitrous  oxide  gas. 

Later  effects,  which  are  said  in  some  instances   to 

*  For  further  particulars  on  this  point  see  a  paper  by  the  authoron 
"Ankle  Clonus  under  Nitrous  O.cide/'  Brit.  Med.  Jour.,  Sep.  24th " 
1837.     . 

D    2 


36  ANESTHETICS. 

ensue  from  the  gas,  are  various  functional  derangements 
of  the  nervous  system,  tinnitus  aurium,  headache,  and 
amaurosis,  but  these  conditions  occur  only  with  the 
most  exceptional  rarity. 


The    Administration  of  Nitrous    Oxide    Gas   and    the 
Purposes  for  which  Applicable. 

When  used  alone,  nitrous  oxide  gas  produces  a  period 
of  anaesthesia  which  seldom  exceeds  a  minute.  Many 
persons,  and  especially  children,  pass  out  of  the  con- 
dition of  unconsciousness  with  very  great  celerity,  and 
in  them  the  anaesthetic  stage  cannot  be  relied  upon 
for  longer  than  15  or  30  seconds. 


General  Surgery. 

Nitrous  oxide  has  been  used  for  prolonged  operations, 
by  narcotising  with  this  gas,  then  letting  the  patient 
almost  resume  consciousness,  and  again  applying  the 
face  piece  and  administering  the  gas.  Dr.  Carnochan 
removed  a  breast,  the  patient  being  kept  under  nitrous 
oxide  for  sixteen  minutes.  And  the  same  surgeon  per- 
formed other  major  operations  with  the  same  anaesthetic. 
Mr.  Bailey  tells  me  he  kept  a  patient  unconscious  for 
forty  minutes  while  a  surgeon  removed  a  malignant 
growth  from  a  male  breast. 

As  a  rule,  when  nitrous  oxide  is  administered  more 
than  once  at  one  sitting,  headache  and  malaise  are 
liable  to  ensue. 

For  the  opening  of  abscesses,  whitlows,  and  car- 
buncles;   for  the  insertion   of  setons  ;    the  tapping  of 


DENTAL,    SURGERY.  37 

antral  abscesses  ;  the  removal  of  portions  of  the  uvula, 
tonsils,  or  nasal  polyps ;  for  cauterising,  and  possibly 
for  the  passing  of  Eustachian  and  other  catheters,  and 
the  slitting  up  of  the  lacrimal  canals,  nitrous  oxide  may 
be  need.  Tenotomy,  divisions  of  fascias,  breaking  down 
adhesions  in  and  about  joints,  and  divisions  of  fistulas, 
may  be  undertaken  with  this  agent,  but  as  a  rule  it  will 
be  found  better  in  such  cases  to  supplement  its  use  with 
that  of  ether. 

Many  other  operations  of  minor  surgery  can  be 
carried  through  under  nitrous  oxide,  and  it  is  possible, 
by  judicious  management,  to  prolong  anaesthesia  for 
several  minutes  by  administering  the  gas  again  and 
again ;  such  a  practice,  however,  cannot  be  commended 
as  it  is  liable  to  produce  headache,  faintness,  and  great 
discomfort  to  the  patient. 


Dental  Surgery. 

Nitrous  oxide  alone,  or  combined  with  a  very  small 
dose  of  ether  in  the  manner  to  be  described  hereafter, 
is  the  safest  and  best  anaesthetic  for  this  branch  of 
surgery.  When  nitrous  oxide  is  used  alone  and  pushed 
to  the  point  of  stertor  and  jactitation,  two  or  three  teeth 
may  be  extracted  at  one  sitting,  and  expertness  in 
operating  may  enable  even  more  to  be  done.  Abnor- 
mality of  the  teeth  or  mouth  may  render  extraction  so 
difficult  as  to  prevent  the  successful  removal  of  one 
tooth  at  a  sitting,  and  in  all  instances  care  should  be 
taken  to  avoid  promising  the  extraction  of  more  than 
two  or  three  unless  the  case  be  manifestly  an  easy  one. 
If  the  extracting  be  kept  up  too  long,  pain  will  be  felt, 


3S  ANESTHETICS. 

aud  the  patient  complain  that  he  could  feel  the  removal 
of  every  tooth ;  to  obviate  such  complaints,  an  operator 
would  do  wisely  to  place  himself  in  the  hands  of  his 
anaesthetist,  who  should  generally  be  better  able  to 
judge  what  may  be  done  with  impunity.  Unless  some 
special  reason  exist  for  desiring  to  extract  several  teeth 
at  one  sitting,  it  is  advisable  to  let  the  patient  attend 
twice  or  thrice  rather  than  to  subject  him  to  more  than 
one  administration  on  the  same  day.  Extracting  a 
number  of  teeth  simultaneously  produces  more  or  less 
severe  shock. 

Apparatus  Required. 

I.  Apparatus  for  giving  nitrous  oxide  alone. 

— The  apparatus  I  find  to  answer  best  is  one  which  is 
here  figured  (fig.  2),  and  which  has  been  made  for  me 
by  Mr.  Blennerhassett,  of  London.  Its  main  peculiari- 
ties are  that  (1)  it  is  provided  with  an  efficient ;'  silencer" 
(K)  which  ensures  absolute  quietude,  (2)  it  is  adapted 
for  gas  only,  and  so  offers  no  temptation  to  the  admin- 
istrator to  give  "  only  a  whiff  of  ether,"  (3)  it  possesses 
a  special  contrivance  to  filter  the  air,  and,  if  necessary, 
to  impregnate  the  gas  with  aromatic  or  other  vapours. 
It  consists  of  the  usual  tripod  (A),  used  because  it  is 
so  portable  and  compact ;  this  supports  a  steel  bottle 
containing  fifty  gallons  of  compressed  nitrous  oxide  (/>). 
To  the  outlet  pipe  (a)  of  this  bottle  is  fixed  the  silencer 
(A),  which  checks  all  the  hissing  and  spluttering  of  gas, 
and  from  this  a  wide-calibred  mohair  tube  conducts  the 
gas  into  the  ordinary  Cattlin's  bag  (0).  Another  tube 
is  attached  to  this,  which  communicates  with  a  chamber 
made  in  metal  and   opened  or  closed  by  a  valve,  per- 


APPARATUS    REQUIRED. 


39 


mitting  either  air  or  nitrous  oxide  gas  to  enter.  In 
this  chamber  (D)  are  placed  morsels  of  fine  honey- 
combed  sponge    or   teased- out  medicated  cotton- wool. 


Fig.  2. — Dr.  Dudley  Buxton's  Apparatus  for  giving  nitrous  oxide, 
(A)  Tripod.  (B)  Steel  b(  ttle  containing  liquefied  nitrous  oxide. 
(C)  India-rubber  bag.  (D)  Chamber  containing  sponge,  cotton- 
wool, etc.  (£")  Face  piece  fitted  with  (/*')  cap  expiration  valve. 
(G)  Tube  for  inflating  the  air  cushion.  (/)  Hook  attaching  tube  to 
administrator's  button  hole.     (K)  Quieter. 


40  ANESTHETICS. 

These  substances  can  be  moistened  with  lavender 
water,  eau  de  Cologne,  or  with  sal  volatile,  or  liq. 
ammonias  dil. — if  a  stimulating  action  is  needed. 
The  ordinary  Clover's  face  piece  (E)  is  attached  by  a 
bent  metal  tube,  and  provided  with  an  expiration  valve 
of  peculiar  construction  (F). 

In  cases  when  the  breath  or  buccal  exhalations  are 
likely  to  be  infective, *  as,  for  example,  in  phthisis,  syphi- 
lis, quinsy,  etc.,  the  use  of  cotton-wool  steeped  in  a  ger- 
micide, such  as  tercbene,  is  desirable.  The  cotton- wool 
is  a  perfect  air  filter,  and  so  prevents  all  infection  of  the 
Cattlin's  bag  and  obviates  any  fear  there  might  be  of 
infecting  the  next  patient.  When  the  ordinary  appara- 
tus is  used  grave  fears  of  such  infection  must  always 
arise.  The  use  of  a  drop  or  two  of  eau  de  Cologne  or 
lavender  water  sprinkled  over  the  morsels  of  sponge  is 
most  convenient.  It  gives  a  pleasant  odour,  which 
children  especially  appreciate,  and  will,  if  permitted  to 
sniff  at  it  before  the  gas  is  turned  on,  allow  one  to  give 
the  first  dose  of  gas — always  the  initial  step  which  is 
difficult — and  so  pave  the  way  to  ultimate  success.  In 
conditions  of  extreme  weakness  or  the  "  feeling  faint," 
which  so  often  attacks  ladies  about  to  have  a  tooth  out, 
sal  volatile,  eau  de  Cologne,  or  liq.  ammon.  dil.  is  of 
service.  It  need  hardly  be  added  that  other  aromatic 
substances  or  stimulating  vapours  may  be  employed  in 
the  same  manner.  The  use  of  the  silencer  and  the 
agreeable  scent  of  the  perfumed  gas,  as   a  rule,  make 

*  The  danger  of  infection  was  pointed  out  some  time  ago  by  a  cor- 
respondent to  tlie  Journal  of  tlm  llritish,  Dental  Association,  who 
recommended  that  a  fresh  Cattlin's  bag  should  be  used  after  each 
case.  This  somewhat  expensive  precaution  is  rendered  unnecessary 
by  my  simple  contrivance. 


APPARATUS    REQUIRED.  41 

nervous  patients  willing  to  inhale  gas  freely,  and  obvi- 
ate the  distressing  noises  in  the  head  and  horrible 
dreams  which  were  often  determined  by  the  hissing  of 
the  gas,  and  which  are  always  intensified  in  the  hyper- 
sesthetic  stage  of  anesthesia. 

II.  Gas  in  combination  -with  ether. — In  cases 
in  which  more  time  is  required  than  nitrous  oxide  gives, 
the  use  of  ether — but  in  conjunction  with  the  gas — is  to 
be  recommended.  The  apparatus  which  I  have  found 
most  serviceable  is  what  was  called  Clover's  Gas  and 
Ether  Inhaler,  although  since  Mr.  Clover's  time  many 
useful  alterations  have  been  made  in  its  construction. 
The  gas  supply  is  derived  from  a  steel  bottle  (fig.  3,  B), 
fixed  as  before  in  a  tripod,  and  the  gas  traverses  an 
india-rubber  tube  (m)  to  the  inhaler  (D).  This  is 
shewn  in  fig.  3.  The  apparatus  is  so  arranged  that 
gas  can  be  given  alone,  or  if  ether  also  is  needed,  by 
turning  a  tap  (k)  the  gas  passes  directly  into  the  re- 
ceiver (C)  containing  ether,  and  having  traversed  it  and 
passed  over  the  surface  of  the  ether,  escapes  into  the 
face  piece  (P)  along  a  tube  (n).  The  amount  of  admix- 
ture of  gas  and  ether  is  regulated  by  another  tap  (o) . 
The  whole  apparatus  is  light,  and  is  suspended  by  a 
hook  (i)  from  the  administrator's  buttonhole.0 

The  advantages  of  this  apparatus  are  : — 

1.  The  absolute  control  the  administrator  possesses 
over  the  strength  of  vapour  with  which  he  is  working ; 
thus  he  would  commence  the  administration  with  pure 
gas,  then  permit  some  gas  to  play  over  the  ether,  and  by 
degrees  permit  full  ether  vapour  without  exciting  spasm 
or  coughing. 

2.  Its  great  simplicity  and  portability.     It  has  been 

*  The  apparatus  is  made  by  Messrs.  Mayer  and  Meltzer,  of  London. 


42 


AX-ESTHETICS. 


termed  unsightly  and  cumbersome,  but  no  one  familiar 
with  its  use  would  find  it  either  the  one  or  the  other. 

3.  It  is  the  only  inhaler  in  which  the  gas  is  made   to 
actually  traverse  the  ether. 


Via.  3. — Apparatus  for  the  administration  of  nitrous  oxide  and  ether 
(After  Mr.  Clover.) 

When   ether   only   is    used    the    same    apparatus    is 
equally  satisfactory. 

In  either  apparatus  the  gas   supply   is   controlled  by 


APPARATUS    REQUIRED.  43 

the  foot,  which,  placed  upon  the  foot  piece  (/)  rotates  it 
from  right  to  left  to  turn  the  gas  on,  and  from  left  to 
right  to  turn  it  off.  Some  persons  prefer  to  have  the 
bottles  placed  horizontally,  thus  obviating  the  necessity 
for  the  tripod.  In  this  case  the  exit  valve  is  so  situated 
that  a  foot  piece  placed  on  the  long  axis  of  the  bottle 
regulates  the  supply. 

When  gas  only  is  required  it  is  always  well  to  have 
two  bottles  yoked  side  by  side  and  connected  by  an 
ordinary  junction,  so  that  when  one  bottle  becomes 
empty,  the  valve  of  the  second  is  opened  and  the  supply 
of  gas  is  not  interrupted. 

When  ether  is  to  be  given  in  succession  to  nitrous 
oxide  the  apparatus  figured  (p.  42)  is  used.  The  pati- 
ent is  rendered  unconscious  with  gas,  and  as  soon  as 
the  quiet  rhythm  of  respiration  assures  us  that  such  is 
the  case  the  stop  cock  is  turned  into  the  long  axis  of 
the  bag,  and  the  indicator,  which  is  seen  in  the  figure 
as  standing  midway  between  the  letter  G  and  E  on  the 
dial  plate  (o),  is  slowly  rotated  from  G  where  it  stands 
when  gas  only  is  being  given.  As  this  indicator  passes 
from  G  towards  E,  more  and  more  ether  vapour  passes 
into  the  face  piece,  until  when  it  stands  at  E  no  fresh 
gas  supply  is  permitted  and  the  patient  breathes  pure 
ether  vapour. 

The  india-rubber  tube,  the  ends  of  which  are  figured 
g  and  m,  is  then  detached  at  m,  but  the  tap  which 
is  there  placed  is  left  open  to  permit  air  to  enter  the 
bag  and  dilute  the  ether  vapour. 

To  complete  the  description,  we  have  only  to  mention 
that  the  cushioned  face  piece  used  by  Clover  and  sup- 
plied with  a  single  expiratory  valve  is  as  convenient  as 
any. 


u 


ANAESTHETICS. 


Should  a  supplemental  bag  be  used,  the  face  piece 
must  be  provided  with  an  aperture  to  which  this  acces- 
sory can  be  adjusted.  The  stop-cock  in  this  arrange- 
ment is  kept  shut  until  the  residual  air  of  the  lungs  is 
presumably   exhausted,  when  it  is  opened,  the  finger  is 


Fig.  4. — A.  Expiratory  Valve.  B.  Inspiratory  Tube  which  gears  on 
to  Cattliu's  Bag.  C.  Supplemental  Bag.  D.  Cap  to  cover 
Mount  when  the  Ether  or  Supplemental  Bag  is  not  used. 

placed  upon  the  expiratory  valve  and  the  patient  al- 
lowed to  breathe  backward  and  forward  into  the  bag. 
When  desirable,  however,  it  is  a  simple  matter  to  con- 
vert the  Cattlin's  bag  itself  into  a  supplemental  bag,  by 


APPARATUS    REQUIRED.  45 

placing  a  finger  upon  the  expiratory  valve,  and  so  caus- 
ing the  patient  to  expire  back  into  the  Cattlin  as  well 
as  inspiring  from  it. 

Where  a  gasometer  is  kept,  a  modification  of  the 
above  apparatus  is  in  use.  A  long  tube  screws  on  to 
the  efferent  pipe  of  the  gasometer,  conveying  the  gas  to 
a  bag  of  2  or  3  gallons'  capacity.  This  may  be  con- 
nected directly  with  a  face  piece  or  conveyed  to  it  by 
another  length  of  tubing,  and  by  using  a  three-way- 
cock  it  is  easy  to  combine  this  apparatus  in  gear  with 
Clover's  smaller  ether  inhaler. 

As  face  pieces  are  almost  universally  employed  in  the 
United  Kingdom,  it  is  scarcely  worth  while  to  describe 
the  mouth  pieces  sometimes  used  in  America.  Briefly, 
we  may  say,  they  are  flute-like  in  shape  and  are  taken 
between  the  teeth.  The  nose  is  slightly  pinched  while 
the  patient  draws  in  the  gas  through  the  opening  in 
the  flute  piece. 

The  employment  of  supplemental  bags  (see  fig.  4,  C) 
has  been  advocated  by  Mr.  Braine.  The  bag  fits  on 
the  face  piece  and  is  guarded  by  a  tap.  The  patient, 
having  presumably  emptied  his  lungs  by  a  few  very 
deep  inspirations,  is  allowed  to  breathe  to  and  fro  into 
the  supplemental  bag,  the  tap  of  which  is  turned  to 
allow  gas  to  enter.  The  gas  supply  and  the  expiratory 
valve  are  closed.  It  may  be  necessary  to  empty  the 
bag  and  refill  from  the  reservoir.  Those  who  employ 
the  supplemental  bag  claim  for  it  that  it  is  economical 
and  produces  a  slightly  more  prolonged  period  of  un- 
consciousness. The  disadvantages  are — it  is  liable  to 
produce  headache,  it  takes  longer  to  get  the  patient 
well  off,  and  it  is,  I  believe,  opposed  to  the  knowledge 
we  now  possess   of  the  physiological  action  of  nitrous 


46 


AX-ESTHETICS. 


oxide  gas,  since  it  gives  a  mixed  narcosis  partly  as- 
phyxial  and  partly  due  to  the  gas  inhaled. 

Another  apparatus  for  the  giving  of  nitrous   oxide, 


Fig.  5.— BarUi'ts  portable  gasometer  for  liquid  nitrous  oxide. 

nnd  one  useful  to  persons  who  desire  to  keep   a   supply 
always  ready  in  their  rooms,  is  figured  above.     (Fig.  5)- 


The  Administration. 

Various  adjuncts  are  used,  such  as  gags,  mouth  open- 
ers, mouth  props,  the  oral  spoon,  tongue  forceps. 


THE    ADMINISTRATION. 


47 


Gags. — Various  forms  are  in  use,  the  one  made  for 
me  has  special  advantages  from  the  facility  it  offers  for 
rapid  removal  and  rej)lacement.  It  consists  in  replac- 
ing the  screw-fixing  arrangement  by  a  ratchet  as  is  seen 
in  the  figure. 

By  putting  the  finger  upon  the  free  end  of  the  ratchet 
and  pressing  it  backwards  as  one  does  a  trigger,  the 
ratchet  is  released  and  the  gag  closes.  To  open  it,  it 
is  only  necessary  to  press  the  handles  together  and  the 


Fig.  6. — Gag  fitted  with  ratchet  arrangement.    (Mayer  and  Meltzer). 

ratchet  will  automatically  gear  and  prevent  closing  of 
the  mouth.  I  find  it  safer  to  wire  the  tube  pads  on 
to  the  ends  of  the  gag ;  this  prevents  their  casting 
loose  in  the  mouth,  and  is  easily  accomplished  when 
the  pads  are  changed,  as  should  frequently  be  done. 
The  ratchet  arrangement  can  be  used  with  long  or  short 
handles,  personally  I  prefer  the  latter. 

The  usual  form  of  gag  (Mason's)  is  figured  p.  48. 

A  very  convenient  gag  has.  been  devised  by  my  friend 
Mr.  Gowan,  which  combines  the  advantages  of  a  sure 
gag  and  a  mouth  opener  in  cases  in  which  the  teeth 
are  sufficiently  apart  to  allow  its  insertion.  It  acts  by 
turning  the  millhead  from  left  to  right,  and  fixes  itself 


48 


ANESTHETICS. 


without  requiring  any  screw.     This  gag  is  as  ingenious 
as  it  is  useful. 


Fig.  7. — Mason's  Gag  (improved  by  Croft). 


Fig.  8. — Gowan's  Gag.  By  revolving  the  disc  a  to  the  right  or  left 
the  gag  is  opened  or  closed.  The  disc  being  eccentric,  no  screw 
is  required  for  adjusting  the  gag. 

Of  mouth  dilators,  or  more  accurately  openers, 
Heister's,  figured  below,  is  the  best.  It  possesses 
enormous  power,  so  it  must  be  used  with  care.      Its 


THE    ADMINISTRATION. 


49 


employment  is  of  course  indicated  in  cases  of  severe 
trismus,  partial  ankylosis,  etc.  The  blades  may  be 
inserted  either  in  a   gap    caused  by  the  previous   ex- 


Fig.  9. — Mouth  Opener  (Reister's). 

traction  of  a  tooth,  and  if  possible  between  the  molars. 
If  placed  between  incisors  the  risk  is  run  of  forcing 
these  teeth  out  of  their  sockets. 

Dental  props. — Many  kinds  are  in  use.  Mr. 
Clover  employed  those  made  of  hard  wood,  but,  although 
very  convenient  and  not  liable  to  slip,  they  are  apt  to 
get  chopped  and  split. 

The  cleanest  and  nicest  I  know  are  those  figured 
below  and  made  of  vulcanite.  I  have  them  made  in  six 
sizes. 


Fig.  10.— Mouth  Props. 

The   mouth   prop    spoken  highly   of  by   Mr.  A.   S. 
Underwood  and  figured  below  is  also  useful.     (Fig.  11). 


50 


ANESTHETICS. 


All  loose  props  should  be  tied  with  fishing  gut,  and  a 
long  piece  made  to  hang  out  of  the  mouth. 

Although  spring  and  mechanical  props  are  objection- 
able upon  the  general  ground  of  their  liability  to  get 
out  of  order  or  to  break,  yet  some  kinds  are  useful,  and 
I  subjoin  illustrations  of  some  of  the  best. 


Fio.  11. 
A  central  prop,  fixing  upon  the  anterior  teeth  with  a 
rotating  arm,  permits  of  operations  upon  one  or  other 
side  of  the  mouth  according  to   the  necessities  of  the 
case.     A  very  convenient  form  is  figured  below. 


Fig.  12.— Weller's  Gag. 


THE    ADMINISTRATION. 


51 


It  possesses  an  easily  working  screw,  which  permits 
of  very  nice  adjustment.  The  plates  should  rest  upon 
more  than  one  tooth  in  each  jaw. 

Dr.  Frederick  Hewitt's  prop  is  also  useful.     (Fig.  13). 

No  mouth  prop  or  cork  should  he  placed  in  the  mouth 
without  being  first  securely  tied  to  a  counterpoise  which 
hangs  out  of  the  mouth,  and  prevents  the  prop  becom- 
ing wedged  in  the  larynx  or  oesophagus  in  the  event 
of  its  slipping.      The  few  minutes  spent  in   carefully 


Fig.  13. 

adjusting  the  prop  between  the  teeth  should  not  be 
grudged,  as  the  after  success  of  the  operation  depends 
largely  upon  the  security  obtained  in  this  manoeuvre. 
It  should  be  adopted  as  a  general  rule,  when  possible, 
that  the  dental  prop  be  placed  not  further  forward  than 
the  bicuspids. 


Fig.  14. 
The  mouth  spoon  (fig.  14),  made  for  me  by  Messrs. 
Ash,  is  safer  than  its  archetype,  the  invention  of  Mr. 
T.  S.  Carter,  in  that  the  shank  of  the  spoon  in  that  in- 

e  2 


52  ANESTHETICS. 

struinent  is  liable  to  separate  from  the  bowl,  and  then  a 
risk  is  run  of  the  detached  bowl  getting  impacted  in  the 
gullet  or  windpipe.  By  carrying  the  shank  to  the 
distal  end  of  the  bowl  as  in  my  pattern,  this  danger  is 
obviated.  The  use  of  the  oral  spoon  is  to  catch  any 
teeth  or  roots  which  may  fall  out  of  the  forceps.  Bi- 
cuspids are  especially  apt  to  spring  out  of  the  beaks. 
The  spoon  is  held  below  the  seat  of  operation,  care 
being  taken  not  to  allow  it  to  get  in  the  way  of  the 
operator. 

The  tongue  forceps  (fig.  15)  figured  below  needs  no 
special  description. 

A  tracheotomy  case  should  always  be  at  hand  when 
an  anaesthetic  is  to  be  administered. 

We  will  now  describe  some  special  manoeuvres  which 
are  resorted  to  in  the  administration  of  nitrous  oxide, 
when  the  mouth  is  open  as  is  necessary  in  dental  opera- 
tions. The  prop  should  be  carefully  fixed  in  the  oppo- 
site side  of  the  mouth  to  that  upon  which  the  operation 
is  to  take  place,  and  a  glance  cast  round  for  artificial 
dentures,  or  an  obturator,  which  if  present  must  be 
removed.  The  patient  is  now  to  be  reassured  by  a  few 
cheering  words,  and  directed  to  breathe  freely.  It  is 
well  to  allow  a  nervous  subject  to  take  several  very 
deep  inspirations  before  applying  the  face  j)iece,  as 
these  clear  the  lungs  and  divert  the  attention  from  a 
supposed  horror  of  "taking  gas."  The  Cattlin  bag  is 
quietly  filled  by  turning  the  toothed  foot  piece  under 
the  foot.  The  face  piece  is  then  lightly  applied  to  the 
patient's  face,  and  retained  by  just  enough  pressure  to 
prevent  the  escape  of  gas  or  the  entrance  of  air.  In  a 
second  or  two,  the  patient  becomes  accustomed  to  the 
face  piece,  and  is  then  instructed  to  take  a  very  deep 


THE    ADMINISTRATION. 


53 


breath.  At  the  instant  of  inspiration  the  stop-cock  is 
turned  so  that  the  patient  breathes  in  the  nitrous  oxide 
from  the  Cattlin's  bag.     During  the   administration  it 


Fig.  15. 


is  important  to  keep  the  bag  full  of  gas,  and  to  do  this 
the  foot  must  from  time  to  time  be  turned  and  gas  be 
allowed  to  flow  from  the  bottle  into  the  bag.     It  is  well 


54  ANESTHETICS. 

to  open  the  ingress  of  gas  during  inspiration  and  close 
it  during  expiration. 

After  the  first  fifteen  or  twenty  seconds,  that  is,  after 
the  lungs  are  presumably  filled  with  nitrous  oxide,  and 
when  gas  is  gaining  tension  in  the  blood,  slight  duski- 
ness of  the  skin  appears,  the  ears  and  finger  tips  darken, 
consciousness,  however,  being  fully  present  for  ten  or 
fifteen  seconds  longer.  In  half  a  minute  the  patient's 
power  of  receiving  impressions  and  reasoning  upon  them 
is  greatly  interfered  with,  and  in  a  few  seconds  later  all 
consciousness  is  lost.  At  this  stage,  incautious  acts 
such  as  touching  the  conjunctiva,  making  loud  noises, 
or  roughly  handling  the  patieut  may  lead  to  his  com- 
pletely regaining  consciousness.  In  from  forty-five 
seconds  to  a  minute  after  the  application  of  the  face 
piece,  the  pupils  will  usually  dilate,  the  eyes  becoming 
dull  and  expressionless,  while  there  may  be  strabismus. 
The  conjunctival  reflex  will  persist,  and  if  the  face  piece 
be  removed  at  this  stage,  the  return  to  consciousness 
will  be  rapid.  There  is,  as  a  rule,  time  for  the  extrac- 
tion of  one  tooth,  if  fairly  loose,  but  not  of  more. 
When  the  inhalation  is  not  checked  at  this  time, 
further  signs  of  deeper  anaesthesia  appear.  In  about  a 
minute  and  a  quarter,  the  breathing  grows  stertorous, 
muscular  movements  of  the  hands  and  feet  supervene, 
and  the  conjunctival  reflex  is  lost.  The  eyeballs  begin 
to  oscillate,  and  if  the  gas  be  still  inhaled  the  breathing 
becomes  slowed  and  even  intermittent.  Should  it  stop 
for  more  than  fifteen  seconds  (Clover),  air  must  at  once 
/iven.  At  this  period  of  deep  anaesthesia  there  is 
great  stress  imposed  upon  the  heart,  so  that  the  pulse 
should  be  watched,  and  if  it  flag  all  further  administra- 
tion should  cease.     The  patient  is  now  ready  for  openi- 


THE    ADMINISTRATION. 


55 


tion,  and  it  is  not  wise  to  attempt  to  push  nitrous  oxide 
beyond  this  point. 

Further  inhalation  of  gas  and  air  intermittently  by 
means  of  a  tube  passed  through  the  nose  and  down  the 
naso-pharynx  has  been  suggested  as  enabling  the  anaes- 
thetist to  maintain  unconsciousness  for  operations  about 
the  mouth  ;  but  it  is  a  method  hardly  to  be  commended, 
and  one  which  presents  few  if  any  advantages  over  that 
of  prolonged  anaesthesia  with  ether  impregnating 
nitrous  oxide,  as  above  described. 

Patients  vary  in  the  time  they  require  to  become 
anaesthetised  by  nitrous  oxide,  and  even  the  same  in- 
dividual will  differ  at  various  times,  being  influenced  by 
general  health,  nervousness,  or  exhaustion  from  pain. 

The  Committee  appointed  by  the  OdontologicaJ  Society 
of  Great  Britain  found  the  following  averages  to  ob- 
tain : — 


Males 

Females 

Children  (under  15) 


Time  Going 
off. 


1  min.  21  sec. 
1     „      16    „ 
1     >i       <j    ,, 


Duration. 


24 
28 
2-2 


Time  from  Com- 
mencement to  Re- 
covery. 


1  min.  55  sec. 
2 

i  !!   40  ,. 


As  a  general  rule,  stertor0  or  slight  jactitation  are 
signs  that  the  patient  is  ready  for  operation.  In  giving 
nitrous  oxide  to  children,  the  face  piece  should  be  re- 

*  Laryngeal  stertor  must  be  carefully  discriminated  from  "snor- 
ing." Patients  with  a  thick  pendulous  uvula  or  enlarged  tonsils  or 
post-nasal  adenoids  start  snoring  a  few  seconds  after  the  commence- 
ment of  inhalation,  persons  also  with  loose  baggy  cheeks  make  a  ster- 
torous-like sound,  but  these  conditions  should  be  ignored.  The  true 
stertor  caused  by  vibration  of  the  arytaeno-epiglottidean  folds  only 
comes  on  after  at  least  a  minute,  and  is  more  vocal  in  character. 


56  ANESTHETICS. 

moved  with  the  very  first  sigu  of  jactitation,  otherwise 
their  small  bodies  become  so  convulsed  that  it  is  diffi- 
cult to  keep  them  still  for  operation,  and  valuable  time 
is  lost  in  the  attempt  to  place  them  in  a  convenient 
position.  It  is  important  to  be  able  to  recognise  the 
tokens  of  returning  consciousness,  so  as  to  know  when 
to  desist  from  further  operative  measures,  and  this  can 
usually  be  done  with  certainty.  In  the  first  place,  the 
normal  colour  of  the  face  returns,  the  lips  change  from 
their  ashen  hue  to  a  natural  crimson.  The  patient 
commonly  moves  a  limb  or  utters  a  cry,  though  not  one 
which  implies  consciousness;  restless  movements  of  the 
body  often  occur.  The  time  which  elapses  between 
removal  of  the  face  piece  and  the  period  of  recovery  to 
consciousness,  varies  somewhat ;  it  may  be  as  short  as 
thirty  seconds  or  less  ;  while,  on  the  other  hand,  it  may 
be  prolonged  to  over  a  minute. 

After  Effects 

Are  as  a  rule  conspicuous  by  their  absence  ;  hysterical 
women  may  laugh  and  cry  and  work  themselves  up  to 
a  pitch  of  excitement,  which  sympathetic  friends  attri- 
bute to  "  the  gas  " ;  persons  exhausted  by  fasting  and 
vigil  or  disease  may  become  faint ;  epileptics  occasion- 
ally have  a  fit  during  the  exhibition  of  the  gas  or  im- 
mediately afterwards.  Vomiting  is  rare  after  nitrous 
oxide  gas,  although  such  a  complication  may  occur  with 
children,  or  if  the  anaesthetic  be  given  immediately  after 
a  meal.  Pareira  states  that  in  one  case  loss  of  taste 
followed  it,  and  I  have  met  with  one  in  which  anosmia 
was  compkined  of  for  some  days  subsequently  to  the 
extraction  of  a  tooth  under  gas.     Among  a  few  persons 


DANGERS    ATTENDING    ADMINISTRATION.  57 

of  peculiar  organisation,  certain  nervous  symptoms 
have  been  known  to  follow,  as,  for  instance,  severe 
headache  and  general  malaise.  Such  symptoms,  how- 
ever, are  rare  after  a  single  administration,  but  are  less 
infrequent  when  the  gas  is  repeated  twice  at  one  sitting, 
so  that  it  is  distinctly  inadvisable  to  repeat  the  dose  im- 
mediately. 

Dangers  Attending  Nitrous  Oxide  Administration. 

Syncope. — Among  the  graver  complications  may 
be  noted  syncope.  "While  syncope  seldom  occurs  dur- 
ing nitrous  oxide  narcosis,  it  is  undoubtedly  a  possible 
danger,  especially  among  the  neurotic  and  the  feeble. 
It  may  occur  before  complete  unconsciousness,  and  is 
then  probably  due  in  part  to  subjective  sensations,  such 
as  dread  of  the  impending  operation,  terror  of  the  anaes- 
thetic, or  fear  of  suffocation.  There  are  reported  cases 
where  syncope  has  only  been  observed  after  removal 
of  the  face  piece,  while  in  others,  all  has  apparently 
gone  well  until  the  operation  had  commenced,  when 
the  condition  of  the  patient  suddenly  became  alarming. 
Whether  death  from  syncope  due  wholly  and  solely  to 
nitrous  oxide  has  ever  taken  place  is  doubtful.  In  the 
few  fatalities  which  have  attended  its  use  and  been  re- 
ported, incomplete  anaesthesia  has  played  an  important 
part,  while  fright  and  shock  have  undoubtedly  gone  far 
in  bringing  about  the  untoward  event. 

Faintness. — Less  severe  forms  of  heart  failure, 
however,  such  as  faintness,  do  sometimes  supervene, 
and  should  be  met  by  placing  the  patient  prone  on  the 
ground,  chafing  the  hands,  applying  smelling  salts,  or 
aromatic  vinegar  to  the  nostrils,  and  slapping  the  face 


58  ANESTHETICS. 

and  chest  with  towels  wrung  out  in  very  cold  water. 
All  garments  about  the  waist,  chest  and  neck  should  be 
loosened  if  this  has  not  been  done,  as  it  should  have 
been,  before  the  gas  was  administered.  The  inhala- 
tion of  a  few  whirls  of  nitrite  of  amyl  will,  by  emptying 
the  blood  into  the  dilated  arterioles,  relieve  the  heart. 
It  is  sometimes  advised  to  inject  ether  under  the  skin, 
but  the  utility  of  this  is  doubtful,  nor  is  it  likely  to  be 
called  for  in  the  class  of  cases  above  mentioned. 

A  measure  which  I  have  practically  tested  and  have 
reason  to  estimate  very  highly  is  total  inversion  of  the 
patient.  In  the  moveable  dental  chairs  so  commonly 
used  this  can  be  done  even  in  the  case  of  ladies  without 
indelicacy  or  difficulty. 

Respiratory    difficulties Breathing    in    some 

cases  becomes  very  shallow  and  may  stop  altogether, 
but  this  need  not  cause  alarm  unless  indeed  it  should 
cease  for  longer  than  five  or  six  seconds.  Then  it  is 
well  to  press  up  tli2  ribs  from  below  by  standing  in 
front  of  the  patient,  and  grasping  the  chest  with  both 
hands  placed  about  the  lower  half  ot  the  bony  thorax. 
This  simple  manoeuvre  will  initiate  spontaneous  respira- 
tions, and  all  will  go  well. 

Asphyxia  caused  by  foreign  bodies. — Among 
dangers  occurring  during  nitrous  oxide  narcosis,  must 
be  mentioned  those  which  arise  rather  from  surgical 
interference  than  from  the  agent  -employed.  Thus, 
when  a  prop  is  placed  between  the  teeth,  it  should 
}){■  guarded  from  slipping  back  into  the  wind-pipe 
by  being  tied  to  another  hanging  freely  outside  the 
mouth,  and  the  props  used  should  be  made  of  some 
material  not  liable  to  crack  or  break  off.  The  mouth 
should  be  cleared  of  artificial  dentures,  especially  small 


DANGERS    ATTENDING    ADMINISTRATION.  59 

plates.  Accidents  have  arisen  from  teeth  or  portions 
of  teeth  being  allowed  to  fall  from  the  beaks  of  forceps 
back  over  the  glottis,  a  deep  inspiration  then  drawing 
the  tooth  into  the  trachea.  The  tooth  forceps  have  in 
recorded  cases  broken,  and  a  fragment  become  lodged 
in  the  trachea. 

The  dangers  of  these  casualties  are  :  (1)  immediate  ; 
from  asphyxia  due  to  laryngeal  spasm  excited  by  the 
foreign  body  becoming  entangled  in  the  larynx;  and  (2) 
secondary ;  from  the  working  down  of  the  foreign  body 
into  the  bifurcation  of  the  trachea  and  there  setting  up 
pulmonary  trouble. 

To  deal  with  such  cases. — Firstly,  as  to  precautions. 
All  instruments  used  for  the  mouth  should  be  carefully 
examined  for  flaws,  and  all  gags,  props,  &c,  be  secured 
by  fishing  gut  or  some  strong  cleanly  material  and  at- 
tached outside  the  mouth. 

In  extracting  teeth  the  forceps  should  after  each  ex- 
traction be  wiped  quickly  twice  across  a  napkin,  in  order 
to  free  them  from  the  tooth  just  removed  before  at- 
tacking another.  Fragments  of  teeth  should  never  be 
left  loose  in  the  mouth,  even  with  the  object  of  gaining 
time ;  each  should  be  removed  before  proceeding  any 
further. 

Some  operators  employ  a  phased  lattice  mouth-spoon 
(see  fig.  14)  so  held  as  to  catch  whole  or  broken  por- 
tions of  teeth.  Should  there  be  any  fragments  detached 
from  the  tooth  or  forceps,  etc.,  which  cannot  be  seen  and 
picked  out,  the  anaesthetist  may  at  once  bend  the  head 
forwards  and  sweep  the  finger  round  the  mouth  so  as 
to  carry  any  foreign  body  forwards,  when  it  can  be 
seized  and  removed  ;  in  this  way  it  may  sometimes  be 
possible  to  dislodge  a  foreign  body  situate  at  the  epi- 


60  ANESTHETICS. 

glottis.  It  should  be  remembered  that  the  tongue  must 
not  be  drawn  forwards,  as  by  so  doing  the  larynx  will  be 
left  exposed,  the  epiglottis  being  dragged  from  it,  also 
because  the  patient  is  thereby  induced  to  take  a  deep 
inspiration  which  may  cause  the  foreign  body  to  enter 
the  air- passage. 

If  the  obstruction  cannot  be  felt,  and  there  are  signs 
of  impending  asphyxia,  inversion  should  be  attempted, 
and  the  patient  instructed  to  expire  very  deeply,  cough- 
ing with  the  act,  while  he  inspires  as  shallowly  as  he  is 
able.  This  manoeuvre  has  succeeded  in  dislodging  a 
tooth  which  had  passed  into  the  trachea. 

At  the  same  time  it  must  be  remembered  that  inver- 
sion may  cause  the  foreign  body  to  lodge  in  the  larynx 
and  so  excite  spasm.  Failing  these  measures,  if  the 
patient  be  dyspnceic  and  death  by  asphyxia  seems  im- 
minent, the  trachea  must  be  opened  by  the  crico- 
tracheotomy  operation  (see  Chap.  X.). 

Is  nitrous  oxide  dangerous  to  any  particular 
class  of  persons  ? 

It  sometimes  happens  that  the  anaesthetist  is  con- 
sulted as  to  the  safety  and  expediency  of  giving  nitrous 
oxide  to  pregnant  women,  women  during  lactation, 
or  at  the  menstrual  period  ;  persons  whose  vitality  is 
greatly  lowered  by  age  or  disease  ;  the  subjects  of  grave 
heart  or  lung  disease. 

Pregnant  women,  provided  they  be  not  within  a 
very  short  period  of  their  accouchement,  are  not  preju- 
dicially affected  by  laughing  gas.  The  shock  of  a 
surgical  operation,  the  extraction  of  a  tooth  or  what 
not,  is  quite  as  likely  to  provoke  premature  delivery  as 
giving  tin;  gas.  The  child  also  appears  to  be  quite 
unaffected,  as  one  would  expect,  since  its  oxygen  ten- 


DANGERS    ATTENDING    ADMINISTRATION.  61 

sion  is  habitually  low,  and  further  because  the  elimina- 
tion of  nitrous  oxide  from  the  blood  is  very  rapid.  At 
the  same  time,  especial  care  should  be  given  in  admin- 
istering nitrous  oxide  in  these  cases,  as  the  nervous 
system  is  peculiarly  liable  in  these  persons  to  receive 
strong  impressions  and  is  easily  thrown  off  its  balance. 
Hysterical  emotional  outbursts  if  they  occur  will  cer- 
tainly be  attributed  to  the  inhalation,  so  that  unless 
imperatively  called  for,  operative  measures  should  be 
deferred  until  after  parturition.  In  the  early  months 
of  pregnancy  vomiting  may  be  excited  by  nitrous  oxide. 

Lactation  is  not  in  the  majority  of  cases  prejudici- 
ally affected  by  nitrous  oxide  gas.  During  men- 
struation women  may  safely  take  this  anesthetic, 
with  this  reservation  that  since  their  nervous  system  is 
at  this  time  less  stable  than  ordinary,  these  patients 
will  be  a  little  more  likely  to  be  "upset,"  hysterical, 
and  so  on.  It  is  noticed  elsewhere  that  erotic  hallu- 
cinations under  gas  are  more  prone  to  occur  at  the 
"  monthly  period  "  than  at  other  times. 

Age,  as  such,  offers  no  reason  for  declining  to  ad- 
minister nitrous  oxide,  patients  over  ninety  having 
taken  it  successfully.  When  great  vascular  feeble- 
ness exists,  there  is  more  risk,  as  the  greater  tax  im- 
posed upon  the  heart  by  checking  oxidation  in  the 
lungs,  and  so  impoverishing  the  tissues,  may  provoke 
syncope.  However,  with  due  care  and  watchfulness 
even  the  very  feeblest  can  take  nitrous  oxide  with 
impunity.  In  practice  I  have  found  it  wise  to  admin- 
ister a  little  ether  in  conjunction  with  the  gas  when 
great  circulatory  enfeeblement  is  present. 

In  extensive  lung  disease,  especially  in  phthisis, 
when  hemorrhage  has  been  known   to  have  occurred, 


62  AX-ESTHETICS. 

nitrous  oxide  must  be  given  with  caution,  as  there  is 
danger  of  exciting  fresh  bleeding  from  the  lungs.  Ac- 
cording to  Mr.  Braine,  narcosis  deepens  in  phthisical 
patients  after  the  withdrawal  of  the  face  piece,  and  so 
special  care  is  needed  in  the  management  of  such  cases. 
It  is  probable  that  this  is  really  due  to  enfeebled  expi- 
ration preventing  the  usual  elimination  of  the  nitrous 
oxide. 

Heart  disease,  save  in  so  far  as  that  the  tendency 
to  syncope  is  considerably  increased,  is  no  contra-indi- 
cation  for  giving  the  gas.  In  all  cases,  it  is  necessary 
to  weigh  in  one's  mind  which  will  be  most  likely  to 
jeopardise  the  patient's  welfare — the  performance  of  an 
operation  without  an  anaesthetic,  or  the  giving  of  the 
anaesthetic.  Broadly  it  may  be  stated  that  if  the  pati- 
ent can  bear  up  against  the  operation,  he  will  certainly 
survive  the  anaesthetic.  (Snow).  Valvular  diseases, 
unless  marked  wrant  of  compensation  is  present,  are 
not  contra-indicatory  to  nitrous  oxide  inhalation. 
When  the  heart  is  greatly  dilated  and  the  hypertrophy 
has  failed  to  overcome  the  obstructed  circulation,  or 
when  marked  muscular  degeneration  of  the  heart  fibres 
has  taken  place,  there  is  necessity  for  caution,  and  of 
such  patients  the  most  anxious  care  should  be  taken. 

Laryngeal  spasm  is  said  to  occur  in  rare  instances 
during  the  administration  ot  nitrous  oxide  gas  even 
when  the  gas  is  pure  and  given  with  skill.0 

•  An  instructive  case  is  published  by  Dr.  F.  Hewitt.  A  patient  set.  35 
Buffered  from  fixation  of  the  bodies  of  the  vertebraa  which  precluded 
all  save  very  slight  rotatory  rmd  nutatory  movements.  The  Deck 
muscles  were  unduly  rigid  and  the  jaws  could  be  opened  only  to  a 
fourth  of  the  normal  extent.  The  fixation  was  the  result  of  rheu- 
matic fever.  The  gas  was  taken  well  and  the  tooth  extracted.  It 
was  then  remarked  that  the  usual  recovery  did  not  occur,  the  respira* 


DEATHS    FROM    ADMINISTRATION.  63 


Deaths  from  Nitrous  Oxide  Administration. 

Several  deaths  have  been  imputed  to  the  use  of  this 
agent,  but  it  is  doubtful  whether  any  of  the  cases 
recorded  were  directly  due  to  the  physiological  action 
of  this  substance.  Iu  some  instances  insufficient  nar- 
cosis was  maintained,  and  as  a  result  the  patient  felt 
the  pain,  and  syncope  ensued.  In  others,  either  the 
entire  gag  or  a  portion  of  it  slipped,  and  found  its  way 
into  the  patient's  larynx,  there  to  excite  spasm  and  suf- 
focation. In  one  instance,  a  person  apparently  whilst 
intoxicated,  kept  the  face  piece  applied  and  fixed  it  so 
that  he  became  asphyxiated. 


Paul  Bert's  Method  of  Administering  Nitrous  Oxide. 

Paul  Bert,  in  the  course  of  various  experiments  under- 
taken to  ascertain  the  most  safe  and  advantageous 
method  of  establishing  anaesthesia  by  nitrous  oxide, 
found  that  by  administering  it  in  conjunction  with 
oxygen  under  pressure,  he  could  prolong  the  adminis- 
tration practically  for  an  indefinite  period,  while  no 
injury  to  the  subject  resulted.  "Without  referring  in 
detail  to  Bert's  experiments,  which  are  out  of  place  in 

tion  becoming  more  and  more  embarrassed  "  as  though  some  ob- 
structive condition  of  the  air  passages  "  existed.  "  The  sound  made 
by  the  last  attempt  at  respiration  was  to  a  certain  extent  suggestive 
of  fluid  at  the  back  of  the  throat."  General  fixation  of  the  thoracic 
walls  and  rigidity  of  the  jaws  and  muscles  of  the  neck  rendered  the 
measures  usually  adopted,  such  as  artificial  respiration,  swobbing 
out  the  pharynx,  &c,  impossible ;  and  as  inversion  failed  to  restore 
the  patient's  respiration,  Dr.  Hewitt  performed  la ryngotomy  which  at 
once  relieved  the  spasm  and  the  patient  did  well. 


64  ANESTHETICS. 

a  practical  manual,  it  may  be  well  to  epitomise  bis 
reasoning  and  give  bis  results. 

Nitrous  oxide,  when  diluted  to  a  certain  point  with 
air  or  oxygen,  is  incapable  of  producing  satisfactory 
anaesthesia.  TVhen,  however,  it  is  given  pure,  the 
patient's  tissues  become  de-oxidised  from  want  of  fresh 
income  of  oxygen.  Further,  nitrous  oxide  does  not 
produce  anaesthesia  by  dint  of  its  replacing  oxygen, 
nor  is  it  rendered  inoperative  in  the  presence  of  oxygen, 
provided  its  tension  in  the  blood  be  sufficiently  high. 
It  therefore  appeared  probable  that,  were  nitrous  oxide 
to  be  administered  under  a  pressure  of  two  atmospheres 
(that  is,  so  that  fifty  per  cent,  only  of  the  atmosphere 
so  inhaled  was  nitrous  oxide,  and  the  other  fifty  per 
cent,  air,  the  nitrous  oxide  tension  in  the  blood  being 
then  equal  to  one  atmosphere,  and  at  the  same  time 
sufficient  oxygen  entered  the  blood  to  maintain  the  due 
oxidation  of  the  tissues),  anaesthesia  would  result  with- 
out any  asphyxia.  An  apparatus  was  accordingly  made 
by  Dr.  Fontaine  (fig.  16)  which  enabled  the  patient  to  be 
kept  under  an  atmospheric  pressure  equal  to  26  inches 
mercury,  and  this  was  successfully  worked.  Under 
this  pressure  nitrous  oxide  and  oxygen  being  given  in 
the  proportion  of  5  to  1,  the  tension  of  nitrous  oxide 
was  equivalent  to  one  atmosphere.0  Several  opera- 
tions lasting  from  five  minutes  to  half  an  hour  were 
successfully  performed  under  anaesthesia  produced  by 
Bert's  method. 

Recently  Dr.  F.  Hewitt  has  revived  Paul  Bert's  idea  of 

*  For  an  excellent  account  of  Paul  Bert's  method  see  the  admir- 
able work  of  M.  Rottenstein,  Anetltdsie  Clnrurgicale.  M.  Rotten- 
stein  assures  me  that  even  in  France  this  method  is  now  but  little 
used. 


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66  ANESTHETICS. 

blending  nitrous  oxide  with  oxygen,  and  has  made 
some  very  careful  experiments.  Filling  a  gasometer 
with  these  gases  in  the  proportion  of  14*5  per  cent, 
oxygen  he  allows  the  patient  to  inhale  strongly  for 
several  minutes,  and  when  he  judges  that  anaesthe- 
sia is  complete  the  operation  is  commenced.  The 
advantages  claimed  for  this  mixture  are  that  no  jacti- 
tation, lividity,  or  respiratory  difficulty  occurs.  The 
disadvantages  appear  to  he  the  uncertainty  of  its  ac- 
tion, the  length  of  time  the  patient  takes  to  become 
anaesthetised  (about  three  times  as  long  as  gas),  and  the 
difficulty  of  ascertaining  when  consciousness  has  ceased. 
Dr.  Hewitt  gives  the  following  indications  : — "  The  ex- 
tremities are  relaxed,  the  eyelids  can  be  raised  with  the 
finger  without  inducing  spasm,  the  eyeballs  are  vacantly 
fixed  or  present  slight  movements  of  oscillation,  the 
patient  does  not  open  his  eyes  when  requested  to  do  so, 
and  the  respiration  is  extremely  calm."  Sometimes 
slight  rigidity  replaces  relaxation ;  corneal  reflex  is 
retained ;  no  change  of  colour  takes  place.  From 
twelve  gallons  of  the  mixture  are  required  for  each 
case.  An  apparatus  has  been  constructed  for  Dr. 
Hewitt  by  Messrs.  Barth,  which  is  fairly  portable, 
and  is  said  to  auswer  its  purpose  very  well. 


CHEMICAL    AND    PHYSICAL    PROPERTIES.  67 


CHAPTEE   IV. 

Sulphuric  Ether — Anaesthetic  Ether. 

Ether  or  Ethyl  Ether  C2H520,  more  accurately  known 
as  oxide  of  ethyl,  was  discovered  in  1540  by  Valerius 
Cordius,  and  called  by  him  oleum  vitrioli  dulce.  In 
1730,  Frobenius  changed  this  name  for  the  one  it  now 
commonly  bears. 

Chemical  and  Physical  Properties. — It  is  a  clear,  trans- 
lucent highly  volatile  liquid,  of  a  penetrating  odour  and 
a  burning  taste  which  is  followed  by  a  sensation  of 
cold  and  numbness.  It  has  a  specific  gravity  of  "723 
(at  54-5°  F.)  and  boils  at  35°  C.  (95°  F.) ;  when  pure  it 
does  not  redden  litmus.  It  cr}Tstallises  in  fine  white 
laminae.  Ether  does  not  mix  with,  but  is  slightly 
soluble  in  water,  freely  uniting  with  alcohol  and  chloro- 
form. Applied  to  the  skin,  it  gives  a  sensation  of  in- 
tense cold  caused  by  the  extreme  rapidity  of  its 
evaporation. 

Ether  is  highly  inflammable  ;  its  vapour  when  mixed 
with  air  is  liable  to  explode  if  brought  in  contact  with 
flame  ;  it  is  hence  important  to  avoid  the  proximity  of 
lighted  gas  jets,  candles,  &c,  and  to  refrain  from  pour- 
ing ether  out  of  one  receptacle  into  another  in  such  sur- 
roundings. The  substance  is  prepared  by  acting  upon 
strong  alcohol  with  sulphuric  acid  and  heating  the  mix- 
ture to  140°-1503  C.  (280°-300°  F.).  This  compound 
undergoes  double  decomposition,  ethyl  sulphuric  acid 
and  water  being  first  liberated,  the  ethyl  sulphuric  acid 

fT2 


68  ANESTHETICS. 

afterwards  combining  with  a  molecule  of  alcohol  to  form 
ethyl  ether  and  sulphuric  acid,  thus  : — 

C2H50  +  HS04  =  HO     +  HS04 
H  H       H  C2H6 

HSO,  +  C2H50  =  HSO,  +  C2H50 
C2H5  H       H  C2H5 

and  the  sulphuric  acid  is  ready  to  attack  another  mole- 
cule of  alcohol.  This,  the  so-called  continuous  ether- 
isation process,  is  practically  interminable,  provided  a 
fresh  supply  of  alcohol  be  maintained.  The  ether  so 
prepared  is  passed  over  fused  chloride  of  calcium,  which 
removes  the  water  and  alcohol  and  is  then  rectified. 

Ether,  if  kept  in  hot  places  and  in  an  imperfectly 
stoppered  bottle,  is  liable  to  undergo  oxidation,  acetic 
acid  and  other  products  form,  and  the  reagent  is  thus 
rendered  unfit  for  use.  Ether,  if  pure,  forms  a  clear 
mixture  with  oil  of  copaiba,  but  if  it  contains  water  or 
alcohol  an  emulsion  will  result. 

The  impurities  to  which  ether  is  subject  are  : — 

1.  Water,  detected  by  adding  tannin,  for  when  water 
is  present  the  mixture  becomes  syrup}',  while  if  absent 
the  powdered  tannin  remains  unchanged. 

2.  Alcohol,  if  present,  gives  a  red  stain  with  crystals 
of  fuchsine  ;  it  also  increases  the  specific  gravity. 

3.  Acids,  sulphuric  and  sulphurous,  detected  by  the 
precipitate  they  give  with  'barium  chloride  ;  acetic  acid 
which  produces  a  deep-red  colour  upon  the  addition  of 
an  iron  salt. 

4.  Fusel  oil,  may  be  detected  by  its  leaving  a  greasy 
stain  on  paper. 

General  properties  and  uses. — Ether  is  an  exhilarant 
and  finally  a  narcotic ;  it  is  the  safest  known  agent  for 
the  production  of  prolonged  narcosis.     It  is  employed 


CHEMICAL    AND    PHYSICAL    PROPERTIES.  69 

alike  for  its  power  of  producing  local  anaesthesia,  which 
it  does  by  provoking  such  a  rapid  abstraction  of  heat  as 
to  numb  the  cutaneous  endings  of  the  sensory  nerves, 
and  also  on  account  of  its  capacity  for  inducing  com- 
plete insensibility  to  pain  (general  anaesthesia)  through 
its  action  upon  the  cerebro- spinal  centres. 

Ether  for  general  purposes  is  the  best  and  safest 
anaesthetic ;  it  is  superior  to  nitrous  oxide,  because  it 
may  be  inhaled  for  hours  without  endangering  life  ;  it 
is  less  dangerous  than  chloroform  because  its  undiluted 
vapour  is  practically  safe,  whereas  chloroform,  unless 
kept  below  four  per  cent,  of  the  air  breathed,  seriously 
imperils  life. 

There  are,  however,  cases  in  which  ether  should  not 
be  used. 

In  protracted  operations  about  the  mouth,  jaws, 
nose  or  pharynx,  which  necessitate  the  mouth  and  nose 
being  uncovered.  Since  consciousness  rapidly  returns 
when  the  supply  of  ether  is  discontinued,  there  is  not 
time  for  prolonged  surgical  procedure. 

All  operations  which  require  the  employment  of  the 
actual  cautery,  or  lighted  candles,  lamps,  &c,  near  the 
mouth,  ether  being  highly  inflammable  and,  when 
mixed  with  air,  detonating,  so  that  the  incautious 
bringing  of  the  apparatus  near  a  light  may  lead  to 
grave  consequences. 

There  are.  also,  certain  conditions  in  which  the  ad- 
visability of  using  ether  ought  to  be  carefully  weighed. 

Persons  who  are  suffering  from  bronchitis,  the  em- 
physematous (if  the  condition  be  very  pronounced),  and 
as  a  rule  asthmatics,  bear  ether  badly,  since  it  excites 
cough  and  may  clog  the  bronchial  tubes  with  a  quantity 
of  excessive  secretion. 


70  ANESTHETICS. 

In  renal  disease,  when  extensive,  ether  is  said  to 
induce  suppression  of  urine,  so  that  if  given  at  all  in 
these  cases  it  should  he  with  the  utmost  caution. 

The  vascular  excitement  to  which  ether  gives  rise 
contra-indicates  its  use  for  persons  whose  arteries  are 
presumably  brittle,  or  in  whom  circulatory  perturbation 
is  likely  to  be  harmful.  It  is  obvious  that  when  cere- 
bral hemorrhage  from  rupture  of  an  artery  has  once 
occurred,  ether  might,  by  increasing  arterial  tension, 
induce  a  repetition  of  so  dangerous  an  accident. 

In  infants  and  very  young  children  ether  may  some- 
times produce  pulmonary  trouble  from  its  irritating 
effects  upon  the  delicate  mucous  membrane  of  the 
respiratory  tract. 

Although,  in  selecting  an  anaesthetic,  it  is  well  to 
carefully  consider  these  objections,  yet,  I  think  few  of 
them  are  of  great  weight  except  perhaps  in  very  marked 
cases  of  disease. 

In  tropical  climates  it  is  both  difficult  to  obtain  and 
to  keep  ether,  and  also  to  administer  it  satisfactorily. 

As  ether  often  provokes  rapid  breathing  and  not  in- 
frequently coughing,  it  should  not  be  used  when  these 
are  prejudicial  to  the  patient,  or  to  the  success  of  the 
operation. 

In  operating  upon  the  brain  when  turgescence  and 
relaxation  of  the  blood-vessels  is  undesirable,  ether 
should  not  be  used,  and  according  to  Wood  it  is  contra- 
indicated  in  the  presence  of  brain  tumours. 

Physiological  Action  of  Ether. 

According  to  Hermann  it  destroys  the  red  corpuscles. 
Ether  when  first  inhaled  induces  a   burning  sensa- 


PHYSIOLOGICAL    ACTION    OF    ETHER.  71 

tion  in  the  mouth  and  pharynx  and  a  feeling  of  impend- 
ing suffocation.  It  appears  to  act  in  two  ways ;  indirectly 
through  the  nerve  centres  as  a  powerful  deliriant  and 
anaesthetic,  and  directly  upon  the  endings  of  the  nerves 
supplying  the  pharynx  and  respiratory  tract.  Thus,  it 
increases  the  flow  of  saliva,  and  causes  considerable 
discharge  of  watery  secretion  from  the  bronchial  mucous 
membrane.  Its  extreme  volatility  makes  it  exert  a 
marked  cooling  action  upon  skin  or  mucous  membranes 
when  allowed  to  come  into  contact  with  them ;  and 
further,  the  vapour,  if  injudiciously  employed,  may  ex- 
cite a  highly  prejudicial  chilling  effect  upon  the  bron- 
chial lining  membrane,  resulting  in  catarrh  or  even 
bronchitis.  Ether  is  absorbed  both  by  the  mucous 
membrane  of  the  respiratory  tract  and  that  of  other 
mucous  surfaces,  e.g  ,  the  rectum.  When  ether  vapour 
enters  the  rectum,  the  vapour  is  perceptible  in  the 
breath  after  a  few  minutes. 

In  the  rhythm  of  respiration,  ether  brings  about 
marked  changes.  If  the  full  strength  of  ether  vapour 
be  allowed  to  impinge  upon  the  glottis,  the  adductor 
muscles  are  thrown  into  spasm,  and  the  rima  becomes 
temporarily  closed.  Indeed  ether  has  been  shown  by 
Horsley  and  Semon  to  exert  a  marked  local  action  upon 
the  laryngeal  muscles.  These  observers  have  proved 
that  this  differs  according  to  the  degree  of  anaesthesia 
induced.  Slight  ether  narcosis  causes  adduction,  while 
deep  etherisation  produces  abduction  of  the  vocal  cords, 
and  these  results  obtain  with  strong  or  weak  currents 
and  whether  the  recurrent  laryngeal  nerve  is  divided 
or  left  intact. 

At  first  the  respirations  are  hurried  and  deep,  subse- 
quently they  become  slower   and   more    shallow,  and 


72  ANAESTHETICS. 

would  eventually,  were  ether  pushed  to  such  a  dan- 
gerous extent,  altogether  cease.  This  slowing  aud  final 
cessation  apj)ear  to  be  due  to  ultimate  poisoning  of  the 
respiratory  centre  in  the  medulla. 

The  heart's  action  is  at  first  excited  and  increased  in 
force ;  later  this  subsides,  the  heart  quiets  down,  or 
even  grows  somewhat  weaker,  though  such  weakening 
is  always  trifling.  The  bio  3d  pressure  is  increased 
until  very  deep  narcosis  is  present,  when  a  slight  fall 
of  pressure  occurs.  A  peripheral  vascular  dilatation 
reveals  itself  in  flushing  and  rubescence  of  the  skin, 
together  with  sweating  and  a  roseolous  rash.  Accord- 
ing to  Sansom,  in  the  earlier  stage  of  etherisation, 
capillary  constriction  takes  place.  Under  ether  the 
muscles  at  first  become  rigid  and  firmly  extended,  but 
later  these  conditions  give  place  to  extreme  flaccidity ; 
in  some  persons  the  muscles  maintain  their  rigidity 
much  longer  than  in  others,  while  there  is  a  difference 
in  the  time  which  muscles  in  various  regions  take  to 
relax.  Ringer,  experimenting  on  muscle,  found,  that 
in  frogs,  the  vitality  of  involuntary  muscle  persisted  far 
longer  in  the  case  of  ether  than  in  that  of  chloroform. 
Peristalsis  although  lessened  is  not  abrogated,  even 
when  death  is  induced  by  ether. 

The  nervous  system  during  etherisation  becomes  pro- 
foundly affected.  The  cerebrum  first  succumbs.  Ex- 
citement and  hallucinations  appear,  the  jmtient 
believing  that  he  is  engaged  in  mortal  combat,  or  in 
some  habitual  pursuit.  He  may  struggle  and  cry  out  ; 
soon  his  speech  becomes  thick  and  inarticulate,  his 
struggles  cease  and  his  mind  no  longer  controls  his 
movements.  The  sensory  /wires  of  the  spinal  cord  then 
fail    to    convey    impressions    from    without,    although 


METHODS    OF    ADMINISTRATING    ETHER.  73 

stimulation  of  the  motor  nerves  induces  movements. 
Later,  the  motor  nerves  also  cease  to  respond,  save  to 
powerful  electrical  excitation  (Longet).  The  medulla 
becomes  next  affected  ;  at  first  sensory  impressions  fail 
to  reach  it,  finally  its  motor  centres  become  paralysed, 
respiration  is  arrested,  and  the  heart  ceases  to  beat. 
It  appears  that  these  results  are  due  to  the  direct 
action  of  ether,  conveyed  by  the  blood  to  the  nervous 
centres,  since  they  occur  after  section  of  the  pneumo- 
gastric  nerves,  or  when  the  anaesthetic  is  injected  directly 
into  the  veins.  Hence  it  would  seem  that  ether 
directly  affecting  the  centres  acts  first  as  a  stimulant 
and  later  as  a  depressant.  When  artificial  respiration 
is  maintained,  the  heart  will  continue  to  beat  for  a  pro- 
longed period,  and  this  even  in  spite  of  very  large 
quantities  of  ether.  The  bodily  temperature  is  reduced 
under  ether;  Kappeler  fixes  a  minimum  at  -3°  C,  and 
a  maximum  at  15°  C.  (#5°— 2*7°  F.).  It  increases  the 
secretions  with  perhaps  the  exception  of  that  of  the 
kidneys.  Elimination  takes  place  rapidly  and  is 
mainly  effected  by  the  lungs. 


Methods  of  Administrating  Ether. 

Ether  may  be  given  alone  or  in  combination  with 
nitrous  oxide  gas,  the  latter  method  possessing  the 
following  advantages  : — The  patient  is  spared  the 
disagreeable  smell  and  taste  of  ether ;  he  becomes 
narcotised  more  rapidly  and  without  struggling  or 
excitement. 

The  main  indications  for  the  successful  administra- 
tion of  this   anaesthetic  are  :— that  the   air  inhaled  be 


74  ANESTHETICS. 

saturated  with  ether  vapour,  unsaturated  air  being 
excluded  ;  that  the  vapour  shall  not  escape  into  the 
room  and  impregnate  the  air  breathed  by  the  operators 
and  bystanders  ;  that  during  the  first  few  respirations 
the  patient  shall  inhale  a  vapour  so  dilute  as  not  to 
irritate  his  larynx.  Ether  cannot  be  given  advantage- 
ously from  a  folded  towel. 

Inhalers.  —  Of  these  several  have  been  devised. 
They  may  be  classed  under  two  types,  those  following 
the  plan  of  Mr.  Clover,  and  those  which  are  modifica- 
tions of  the  cone. 

Clover's  Portable  Ether  Inhaler  (Fig.  17)  con- 
sists, as  reference  to  the  figure  indicates,  of  a  dome- 
shaped  ether  receptacle  (a)  pierced  by  a  central  shaft 
(b)  into  which  are  adapted  (i.)  a  tube  bent  at  right 
angles  (c),  which  carries  the  india-rubber  bag  (*/),  into 
this  the  patient  breathes,  and  (ii.)  a  metal  tube  (e)  which 
serves  for  the  attachment  of  the  face-piece  ( f).  Moving 
with  the  face -piece  (f)  is  a  metal  indicator  (g)  which 
as  the  ether  receiver  (a)  rotates  on  (fj  indicates  the 
amount  of  ether  admitted ;  (h)  is  a  tube  and  stop-cock 
for  inflating  the  air  cushion  which  rims  the  face-piece 
and  helps  it  to  fit  the  face  accurately. 

The  face-piece  (fj  is  edged  with  an  air  cushion 
inflated  through  (/«).  The  ether  vessel  and  water 
chamber  (a)  which  surrounds  it  and  maintains  it  at 
the  desired  temperature  for  evaporation,  rotate  upon 
the  mount  of  the  face-piece  (f).  When  the  instrument 
is  first  applied,  the  arm  (/<)  should  be  opposite  the 
patient's  forehead,  and  the  indicator  (//)  which  travels 
round  the  lower  end  of  the  water  chamber  pointing  to 
the  figure  0.  He  now  breathes  directly  in  and  out  of 
the  bag.     The  bag  (d)   should  not  be  placed  in  posi- 


METHODS    OF    ADMINISTRATING    ETHEE. 


75 


tion  until  the  patient  has  taken  two  or  three  inspir- 
ations, it  must  then  he  inflated  hy  blowing  air  into 
it  and  be  fitted  to  the  upper  end  of  the  water  chamber 
as  shown  in  the  figure.  As  the  ether  vessel  is  turned 
round  the  indicator  travelling  from  0  to  1.  2,  3,  and  F 
successively,  the  air  has  to  traverse  the  ether  vessel 
before  reaching  the  bag,  and  so  the  patient  gets  gradu- 
ally a  more  and  more  highly  saturated  ether  atmo- 
sphere.     Two    ounces   of  ether   are   poured   into   the 


Fig.  17.— Clover's  Portable  Ether  Inhaler. 


projecting  arm  (I)  before  the  operation,  and  these 
usually  suffice  for  the  case.  The  opening  is  so  ar- 
ranged as  to  prevent  an  excessive  quantity  being  used 
and  to  guard  against  the  possibility  of  a  few  drops 
escaping  through  the  inner  openings.  The  ether 
vessel  and  surrounding  water  chamber  are  so  arranged, 
that  although  the  vapour  freely  escapes,  no  fluid  over- 
flows in  whatever  position  the  inhaler  may  be  held. 


76  ANESTHETICS. 

The  following  is  the  method  of  using  this  inhaler. 
A  face- piece  of  an  appropriate  size  having  been  se- 
lected, and  two  ounces  of  ether  jxlaced  in  the  receiver, 
the  air-bag  is  removed  and  the  indicator  turned  to  0. 
The  patient  is  then  directed  to  inspire  deeply,  and  the 
face-piece  applied  gently  but  firmly.  Uniform  pressure 
is  well  borne,  while  hard  pressure  if  unequally  distri- 
buted will  not  be  tolerated.  When  the  patient  has 
taken  two  or  three  deep  breaths,  the  air-bag  is  filled  by 
the  administrator  blowing  in  air,  taking  care  not 
simply  to  breath  into  it,  and  is  slipped  into  its  place, 
so  that  the  patient  now  breathes  in  and  out  of  the  bag. 
The  ether  chamber  is  now  moved  so  that  the  indicator 
points  to  the  figure  1  and  the  patient  then  breathes 
one-fourth  ether  and  three-fourths  air.  A  few  breaths 
of  such  a  dilution  of  ether  will  accustom  the  larynx  to 
the  irritating  vapour,  and  so  obviate  coughing,  spasm, 
and  the  wretched  feeling  of  suffocation  which  ensues 
upon  presenting  a  strong  ether  atmosphere  at  the  com- 
mencement of  an  inhalation.  This  tolerance  achieved, 
the  ether  chamber  is  rotated,  till  the  indicator  points 
to  2,  and  the  patient  then  inhales  half  ether  and 
half  air.  If  this  strength  of  vapour  does  not  distress 
him,  the  indicator,  by  further  rotation  of  the  ether 
chamber,  can,  after  a  few  seconds,  be  made  to  point  to 
3  (one-fourth  part  air,  three  parts  ether)  and  then  to  F 
(all  ether).  The  patient  will  in  from  ninety  seconds  to 
two  minutes  and  a  half,  be  completely  unconscious  and 
ready  for  operation.  Some  persons  require  more  ether 
to  put  them  off,  and  those  who  persistently  resist  tak- 
ing the  anaesthetic  by  holding  their  breath  or  by  tak- 
ing the  shallowest  breaths  consistent  with  life,  will  delay 
the    onset    of   unconsciousness    much   longer.      These 


METHODS    OF    ADMINISTRATING    ETHER.  77 

persons  also,  since  they  voluntarily  semi- asphyxiate 
themselves  by  repressing  respiratory  movements,  suffer 
great  additional  discomfort  from  the  feeling  of  suffoca- 
tion they  induce. 

As  soon  as  complete  anaesthesia  is  thoroughly  estab- 
lished, the  indicator  may  be  brought  back  to  2  by 
turning  the  ether  chamber  round  and  there  kept  until 
the  operation  is  over.  It  may  be  necessary  in  warm 
weather,  and  in  the  case  of  prolonged  operations  to 
renew  ether  in  the  receiver.  This  is  easily  done  by 
removing  the  inhaler  from  the  patient's  face,  loosening 
the  cork,  and  pouring  in  a  further  supply. 

The    patient   will,    during    a    prolonged   operation, 
require  the  inhaler  to  be  taken  off  his  face  every  sixth 
breath  or  so,  in  order  that  he  may  take  a  few  inspirations 
of  air.     The  necessity  for  this  will  be  readily  recognised 
by  any  cyanosis  apparent  in  the  face  or  ears,  and  by 
the  character   of  the  respirations   and  the    pulse.     It 
should  be  carefully  borne  in  mind,  that  the  amount  of 
an    anaesthetic   required  to   produce  narcosis  is  much 
greater   than   is    needed   to    maintain    that   condition. 
Also  the  degree  of  narcosis  must  be  varied,  in   corre- 
spondence  with  the  region  of  the    body   upon  which 
operative  measures  are  being  pursued.     When  it   be- 
comes necessary  to  anaesthetise  the  patient  in  the  prone 
or  semiprone  posture,  a  useful  addition  to  the  Clover's 
smaller  ether  inhaler  is  the  angular  adjuster  figured 
below.     This  useful  contrivance  is  the  invention  of  the 
late  Dr.  Charles  Sheppard  (see  fig.  18). 

This  inhaler  was  intended  by  Mr.  Clover  for  the 
administration  of  ether  alone,  but  several  persons  have 
adapted  it  for  the  exhibition  of  that  vapour  in  conjunc- 
tion with  nitrous  oxide  gas,  and  Mr.  Clover  writing  in 


78 


ANESTHETICS. 


1877  himself  says,  "  by  connecting  the  bag  with  a 
supply  of  nitrous  oxide  it  forms  a  tolerably  efficient 
substitute  for  the  gas  and  ether  inhaler."  Thus  by 
attaching  a  stop- cock  in  the  metal  bent  piece  to  which 
the  bag  is  attached,  gas  can  readily  be  admitted  into  it 
by  a  long  india-rubber  tube  coming  directly  from  the 
gas  bottle  (see  Fig.  17,  ft). 

Another   method,  which  has  been  in  use  for   some 


Fig.  IS. 

years  at  University  College  Hospital,  is  to  introduce  a 
three-way  valve  with  stop- cock  between  the  face-piece 
and  its  rotatory  mount.  In  this  apparatus  the  third 
way  is  connected  with  the  supply  tube  of  gas. 

Dr.  Frederic  Hewitt  has  introduced  a  convenient 
form  of  apparatus  for  giving  gas  and  ether  which  is 
figured  below. 


METHODS    OF    ADMINISTRATING    ETHER. 


79 


In  this  apparatus  the  inspiratory  and  expiratory 
valves  are  placed,  not  in  the  face-piece,  hut  in  a  little 
chamber  near  it.  Below  this  valve  chamber  is  a  two- 
way  stop-cock.  The  valves  mav  be  thrown  into  or  out 
of  action  by  the  tap  T  (Fig.  19).  When  T  is  turned  as 
in  the  figure,  the  valves  act  and  all  expirations 
(whether  of  air  or  gas  as  determined  by  the  stop-cock 
below)  escape.  When  T  is  turned  in  an  opposite 
direction,  to  and  fro,  breathing  (of  gas  or  air  as  the 


Fig.  19. — Face-piece,  stop-cock,  and  gas  bag-  for  the  administration  of 
nitrous  oxide  gas  only.     (Dr.  Hewitt's  apparatus). 

case  may  be)  results.  To  use  the  apparatus,  first 
allow  the  patient  to  breathe  air  (in  the  direction  of  the 
dotted  arrow)  and  see  that  the  valves  act  freely.  Then 
turn  on  nitrous  oxide  by  moving  round  the  handle  H. 
Should  nitrous  oxide  unexpectedly  fall  short  the  valve- 
action  may  be  stopped  by  turning  T  and  the  patient 
would  then  breathe  gas  into  and  out  of  the  bag  till 
anaesthesia  occurs. 

The  apparatus  is  so  made   that  a  very  free  draught 


80 


ANESTHETICS. 


through  it  is  permitted,  the  valves,  which  are  of  thin 
india-rubber,  acting  very  easily  and  thus  giving  no 
sense  of  difficulty  in  breathing.  When  nitrous  oxide 
followed  by  ether  is  required,  the  stop- cock,  &c,  can  be 
fixed  to  a  Clover's  portable  apparatus  as  shown  in 
Fig.  20°. 


Fig.  20.—  Face-piece,  Clover's  ether  chamber,  stop-cock,  and  gas  bag 
for  tlie  administration  of  nitrous  oxide  and  ether.  (Dr.  Hewitt's 
apparatus). 

Clover's  larger  inhaler  is  figured  and  described  on 
Fig.  3,  p.  42.  It  is  used  mainly,  if  not  exclusively,  for 
giving  nitrous  oxide  and  ether  in  combination.  The 
method  of  using  it  without  nitrous  oxide  is  simple. 
The  air  bag  is  fully  inflated  by  the  administrator,  who 
then  moves  the  indicator  off  the  dial  plate  ;md  turns  the 

*  For  this  description  I  am  indebted  to  Dr.  Frederic  Hewitt. 


METHODS    OF    ADMINISTRATING    ETHER.  81 

ether  tap  (k).  The  indicator  is  next  turned  to  G  when 
air  only  will  be  taken.  As  soon  as  the  indicator  passes 
towards  E,  ether  begins  to  be  received  ;  the  same  prin- 
ciples and  cautions  guide  the  further  proceedings  with 
this,  as  were  employed  for  the  other  inhaler. 

The  Cone. — This  is   a    contrivance  largely  used  in 


Fig.  21. — Dr.  Ormsby's  ether  inhaler. 

America.  The  ether  is  poured  into  a  cone,  upon  a 
sponge,  and  renewed  from  time  to  time  by  inverting  it 
and  pouring  in  a  fresh  supply. 

Ormsby's  Inhaler. — It  consists  (see  Fig.  21)  of  a 
leather  face-j)iece  with  cushioned  rim,  provided  with 
a  valve,  which  can  be  opened  at  the  pleasure  of  the 
administrator  ;  at  the  top  of  the  face-piece  is  a  cone- 
shaped  wire  cage,  covered  externally  with  leather,  and 

G 


82  ANAESTHETICS. 

leading  into  a  soft  leather  bag  covered  by  a  loose  net 
which  prevents  its  undue  expansion.  In  the  wire  cage, 
a  sponge  is  placed,  and  upon  this  an  ounce  of  ether  is 
poured.  The  apparatus  is  applied  to  the  patient's  face 
and  he  strives  to  take  a  full  breath.  Even  when  the 
valve  is  kept  widely  open  the  sense  of  suffocation  is  so 
great  (the  rush  of  ether  vapour  producing  more  or  less 
spasm),  that  the  patient  struggles  fiercely  to  escape 
what  appears  like  impending  asphyxia. 

Should  it  be  necessary  to  add  fresh  anaesthetic  dur- 
ing the  operation,  it  is  done  by  pouring  ether  down  a 
tube  which  enters  the  centre  of  the  sponge. 

Ormsby's  inhaler  is  open  to  several  objections  ;  e.g., 
it  produces  great  discomfort  by  allowing  undiluted  ether 
vapour  to  impinge  upon  the  larynx ;  the  sponge  is  very 
liable  to  freeze  hard,  and  so  no  evaporation  of  ether 
can  take  place ;  it  occasions  great  struggling  ;  it  is 
wasteful  of  the  ether. 

Messrs.  Krohne  and  Sesemann  have  designed  a 
modified  cone  of  which  a  description  is  given  on  p.  115, 
which  although  designed  for  chloroform  can  be  used 
either  for  ether  or  the  ACE.  mixture. 

For  administering  ether  I  prefer  Clover's  apparatus, 
but  for  the  exhibition  of  the  A.C.E.  mixture,  the  cone 
or  one  of  the  modifications  mentioned  above  is  prefer- 
able as  admitting  of  more  free  air  dilution. 

The  apparatus  for  administering  ether  by  the  rectum 
is  described  on  p.  87. 

Allis'  Inhaler.  (Fig.  22). — Another  useful  form  of 
inhaler  is  that  invented  by  Dr.  Allis  of  Philadelphia, 
supplied  by  Messrs.  Mayer  and  Meltzer.  It  is  applicable 
for  the  use  of  ether  or  the  mixture,  and  is  efficacious  and 
cleanly,  and  is  probably  the  best  form  of  open  inhaler. 


METHODS    OF    ADMINISTRATING    ETHER. 


83 


It  consists,  as  can  be  seen  from  the  wood- cut,  of  a 
metal  frame  so  arranged  that  flannel  bandage  can  be 
stretched  across  and  across.  The  outside  is  covered 
with  a  leather  case,  which  being  prolonged  below  the 


Fig.  22. — Allis'  ether  inhaler. 


metal  serves  as  a  well  adjusting  face-piece.  Fresh 
additions  of  the  anaesthetic  are  dropped  from  time  to 
time  upon  the  flannel  from  above. 

Eendle's  ether  mask  figured  below  needs  no  special 
description.     (Fig.  23). 

Many  other  forms  of  apparatus  have  been  invented, 
but  as  they  possess  no  peculiar  merits  and  are  seldom 

g  2 


84 


ANESTHETICS. 


used  in  this  country,  I  must  omit  further  mention  of 
them. 


Fig.  23. — Rendle's  ma^k  and  flannel  cap  in  cone. 


The  Administration. 

The  effects  of  ether  inhalation  will  vary  considerably 
according  as  the  patient  is  narcotised  rapidly  or  slowly. 
Slow  etherisation  possesses  no  advantages,  and  is  in- 
deed positively  harmful  by  prolonging  the  stage  of 
delirious  excitement. 

The  patient  being  placed  in  the  supine  position  and 
his  clothing  ascertained  to  be  loose,  his  mouth  is  ex- 
amined for  artificial  teeth  or  an  obturator,  and  if  such 
exist  they  are  to  be  taken  out  and  ether  administered 
by  one  of  the  above  forms  of  apparatus.  Although  the 
supine  position  is  best,  yet  for  operations  for  the  re- 
moval of  teeth  and  upon  the  post- nasal  cavity  the 
patient  may  be  allowed  to  be  propped  in  a  sitting 
posture. 

When  the  patient  first  breathes  ether  vapour,  he 
catches  his  breath,  may  cough,  and  resists  the  ingress 


THE    ADMINISTRATION.  85 

of  the  vapour.  This  will  be  in  proportion  to  the 
strength  of  vapour  used.  A  few  inspirations  will 
render  him  dazed,  the  face  will  flush,  the  eyes  grow 
suffused,  and  the  breathing  become  rapid.  The  pulse 
in  this  stage  is  large,  softer  than  natural,  and  acceler- 
ated. Although  stupefied,  the  patient  can  still  perform 
certain  voluntary  acts,  e.g.,  putting  out  the  tongue  if 
loudly  ordered  to  do  so.  The  feeling  of  suffocation 
which  was  at  first  experienced  now  gives  place  to  one 
of  exhilaration,  the  dyspnoea  disappears,  and  the  re- 
spirations are  full  and  deep.  Formication  and  tingling 
are  felt  in  the  hands  and  feet.  The  pupils  usually 
contract  in  this  stage.  The  exhilaration,  however,  soon 
passes  into  a  condition  of  delirious  excitement.  Bert 
denied  that  true  excitement  occurs,  believing  that  pro- 
gressive loss  of  muscular  power  supervenes,  while  the  dis- 
orderly movements  commonly  put  down  to  excitement 
of  delirium  are  he  thought  to  be  explained  as  une  sorte 
cVanarchie  cerebrate,  the  guiding  centres  being  in  abey- 
ance. In  whatever  way  we  regard  these  movements, 
they  certainly  appear  to  be  the  result  of  temporary 
delusions.  Thus,  military  men  will,  in  this  stage  of 
etherisation,  shout  words  of  command ;  while  those 
inclined  to  pugilism  will  attempt  to  box  with  the  by- 
standers. The  respirations  and  heart's  actions  are 
considerably  accelerated ;  the  skin  grows  moist,  the 
face  dusky.  Soon  a  period  of  quiet  follows,  and  it 
should  be  the  aim  of  skilled  etherisation  to  curtail  as 
much  as  possible  this  condition  of  excitement.  In  the 
succeeding  quietude  the  limbs  stiffen,  the  muscles  grow 
strongly  contracted  and  firmly  set,  the  whole  body 
becoming  rigid.  Breathing  is  hampered  by  the  rigidity 
of  the  thoracic  muscles  and  needs   watching   at   this 


86  ANESTHETICS. 

time.  Should  respirations  stop  it  will  be  necessary  to 
firmly  press  two  or  three  times  upon  the  chest,  and  so 
force  in  the  air.  The  pupils  dilate  and  the  skin  be- 
comes bedewed  with  perspiration,  while  a  roseolous 
rash  appears  in  patches  about  the  neck  and  chest. 
These  patches  coalesce.  The  pulse  resumes  its  normal 
rate,  and  although  soft,  yet  remains  regular  and  some- 
what more  forcible  than  before  the  anaesthetic.  Now 
ensues  the  stage  of  muscular  relaxation.  The  patient 
lies  absolutely  insensible  to  all  external  impressions 
with  his  muscles  perfectly  flaccid.  The  breathing 
slows  although  it  keeps  quicker  than  normal,  and  is 
much  more  shallow.  At  this  time  anaesthesia  may  be 
taken  as  complete,  and  operative  measures  may  proceed. 


Rectal  Etherisation. 

PirogofT  as  early  as  1847  suggested  that  ether  should 
be  given  by  the  rectum  and  finding  that  liquid  ether 
could  not  with  impunity  be  injected  (Magendie),  he 
employed  an  apparatus  which  permitted  ether  vapour 
only  to  enter,  and  obtained  such  good  results  that  he 
believed  rectal  etherisation  would  replace  pulmonary 
inhalation.  More  recently  Dr.  Axel  Yversen  of  Copen- 
hagen, Dr.  0.  Wanscher  of  the  same  city,  and  Dr. 
Molliere  of  Lyons  as  well  as  Drs.  Bull  and  Weir  of 
New  York  have  tried  rectal  etherisation  and  speak  well 
of  it. 

I  have  now  used  the  method  pretty  extensively  and 
find  it  to  answer  admirably  for  operations  about  the 
mouth,  nose  and  post-buccal  cavities,  for  intra-  and 
extra- laryngeal  operations,  for  staphylomiphy  and  for 


RECTAL    ETHERISATION.  87 

operations  for  the  relief  of  empyema.  For  the  removal 
of  the  tongue,  for  excision  of  the  jaw,  or  jaws,  and  for 
plastic  operations  about  the  face,  the  method  gives 
greater  facilities  and  freedom  to  the  operator  than  any 
other  plan  I  have  tried.  Mr.  Appleby  recommends  the 
method  also  for  prolonged  dental  operations.  The 
advantages  claimed  are  (i.)  less  ether  is  used,  (ii.)  re- 
covery is  more  rapid,  (hi.)  after  effects  are  less  severe, 
(iv.)  the  stage  of  excitement  is  lessened  or  abrogated. 

Its  disadvantages  are  ;  the  greater  length  of  time  the 
patient  usually  takes  to  become  ready  for  operation 
however  this  does  not  always  apply ;  the  uncomfort- 
able feelings  some  patients  complain  of,  although  Dr. 
Wanscher  says  some  of  his  patients  having  been 
anaesthetised  first  by  the  usual  method  and  subsequently 
by  the  rectum,  preferred  the  latter. 

In  some  cases  it  is  alleged  that  severe  meteorism, 
diarrhoea  and  even  melaena  have  followed  the  use  of 
ether  by  the  rectum.  Unquestionably  the  method  re- 
quires the  greatest  care  and  some  experience  before  a 
uniformly  happy  result  can  be  expected,  and  the  anaes- 
thetist must  remember  that  carelessness  in  permitting 
too  rapid  an  evolution  of  the  vapour  will  lead  to  grave 
suffering  if  not  to  danger. 

The  apparatus  I  have  employed  is  in  effect  an  ether 
receiver  holding  about  2  or  3  ounces,  this  is  plunged 
into  a  second  vessel  which  should  contain  water  at 
120°  F.  The  ether  vessel  communicates  by  an  india- 
rubber  tube  with  a  glass  intercepter  devised  to  prevent 
the  entrance  of  liquid  ether  into  the  rectum  The 
further  end  of  the  intercepter  is  joined  by  another  and 
short  tube  to  an  anal  tube.  This  is  made  for  me  by 
Messis.  Mayer  and  Meltzer.     Some  persons  have   em- 


88  ANESTHETICS. 

ployed  the  water  at  a  higher  temperature,  but  my  ex- 
perience leads  me  to  believe  that  the  untoward 
experiences  which  have  been  recorded  have  in  most, 
if  not  all,  cases  been  brought  about  by  having  the  water 
too  hot,  and  so  permitting  a  too  rapid  evolution  of 
ether  vapour. 

The  usual  signs  of  anesthesia  are  present  and  so 
nothing  need  be  said  about  them.  As  a  rule  children 
go  under  more  rapidly  than  adults,  when  ether  is  given 
by  the  rectum,  but  the  time  occupied  in  inducing  com- 
plete anesthesia  varies  within  wide  limits.  I  have 
succeeded  in  3  minutes  and  have  had  to  wait  15  or  30 
minutes.  Dr.  Stimson  informs  me  that  American  sur- 
geons have  had  several  fatalities  in  employing  this 
method. 

Dangers  and  Accidents  of  Ether  Inhalation. 

The  chief  troubles  which  occur  during  ether  narcosis 
are  connected  with  respiration.  In  the  first  place 
the  breathing  may  be  stopped  through  obstruction  in 
the  larynx,  the  rirna  glottidis  becoming  closed  and  no 
air  entering  the  lungs.  In  some  cases  the  rigidity  of 
the  muscles  may  cause  impediment  to  air  entry  by 
provoking  tight  closure  of  the  teeth.  Inspiration 
through  the  nose  is  greatly  hindered  or  prevented  by 
the  nostrils  being  sucked  in  with  inspiration.  In  this 
way  little  air  can  enter  the  chest  and  the  patient  grows 
cyanotic.  If  the  teeth  be  forcibly  opened  by  a  screw 
gag,  air  will  enter  freely  and  the  cyanosis  pass  off. 
The  movements  of  respiration  do  not  cease  in  the  con- 
dition of  laryngeal  spasm,  whether  partial  or  complete. 
In  edentulous  persons  with  long  flabby  lips,  these  are 
sucked  in  and  act  as  a  kind  of  valve  permitting  expira- 


DANGERS    AND    ACCIDENTS    OF    ETHER    INHALATION.        8d 

tion  but  hindering  inspiration.  To  obviate  this  I  have 
found  keeping  the  jaws  apart  by  a  Fergusson's  gag 
useful,  and  administering  the  ether  with  the  mouth  so 
propped  open. 

Treatment. — The  head  must  be  thrown  back  and  the 
tongue  drawn  forward  ;  by  this  means  respiration  may 
be  induced  to  start,  but  failing  this,  tracheotomy  must 
be  performed. 

A  more  troublesome,  although  fortunately  rare 
complication  occurs,  when  the  thorax  becomes  fixed  by 
the  rigidity  of  its  covering  muscles.  The  treatment 
here  is  to  maintain  the  air  way  open,  and  to  attempt  to 
overcome  spasm  by  artificial  respiration.  In  spas- 
modic fixation  of  the  thorax,  abdominal  respiration 
must  be  practised,  and  the  floating  ribs  compressed  in 
expiration.  Stimulation  of  the  nasal  mucous  mem- 
brane will  sometimes  initiate  a  deep  inspiration.  This 
can  be  done  with  quills  of  bibulous  paper  soaked  in 
sal  volatile  or  an  ammoniacal  solution. 

But  if  ether  be  incautiously  pushed  for  a  prolonged 
period,  without  allowing  the  patient  to  renew  the  air  in 
his  lungs  from  time  to  time,  the  respiration  may  stop 
altogether,  although  the  muscles  will  be  quite  flaccid. 
This  condition  would  appear  to  ensue  upon  the  over- 
loading of  the  blood  with  ether,  leading  to  poisoning  of 
the  respiratory  centre.  The  treatment  is  the  immediate 
performance  of  artificial  respiration.  If  this  be  properly 
done  the  blood  soon  becomes  duly  oxygenated,  and 
the  nerve-centres  being  once  more  supplied  with  de- 
purated blood,  recover  their  control  over  the  respiratory 
mechanism,  and  so  natural  respiration  ensues. 

Barely,  the  heart  may  give  trouble.  In  a  few 
recorded  cases  fatal  syncope  has  occurred  at  the  com- 


90  ANESTHETICS. 

rncncemeut  of  ether  inhalation,  but  whether  such 
casualities  can  be  justly  imputed  solely  to  ether  in- 
fluence, is  I  think  doubtful. 

Less  important  inconveniences  of  ether  inhalation 
are  the  increased  secretion  from  the  mouth  and  respira- 
tory tract ;  this  although  interfering  with  respiration  is 
seldom  of  any  great  importance.  It  must  be  remem- 
bered, however,  that  in  infants  and  weakly  persons  it 
may  prove  a  grave  after  complication,  giving  rise  to 
blocking  of  the  tubes  and  water- logging  of  the  lungs. 

Coughing  occurs  in  many  persons,  especially  if 
ether  vapour  be  given  in  too  concentrated  a  form  ;  but 
it  is  a  mistake  to  remove  the  inhaler  for  this  in  all 
cases,  as  frequently  while  a  dry  cough  occurs  in  the 
earlier  stages  of  etherisation,  it  is  suppressed  by  push- 
ing the  anaesthetic. 

Vomiting  during  the  operation  is  nearly  always  due 
to  the  giving  of  too  little  ether,  and  follows  upon  the 
partial  resumption  of  consciousness.  The  patient  will 
be  observed  to  inspire  irregularly  with  shallow  breaths, 
followed  now  and  again  by  yawning  inspirations.  This 
will  be  succeeded  by  efforts  at  swallowing,  rapid  and 
chiefly  abdominal  inspirations  ensue,  and  the  patient 
retches  and  vomits.  Conjunctival  reflex  returns  just 
before  the  sickness. 

Treatment. — Two  indications  are  now  paramount,  to 
get  rid  of  the  vomited  matter  and  to  avoid  any  of  it 
being  drawn  into  the  larynx  by  the  deep  inspiration 
which  always  follows  the  act  of  vomiting  ;  secondly 
to  prevent  complete  return  to  consciousness.  To  obvi- 
ate these  the  patient's  head  should  be  turned  to  one 
side  without  being  raised  and  all  vomit  removed  with 
the  finger ;    then    the   inhaler    should   be   rapidly  re- 


AFTER    EFFECTS    OF    ETHER.  91 

applied,  and  if  further  vomiting  occur  recourse  must 
be  bad  to  similar  manoeuvres.  But  a  judicious  pushing 
of  the  anaesthetic  at  the  first  signs  of  the  onset  of 
vomiting  will  often,  if  not  always,  prevent  the  oc- 
currence of  sickness.  In  carrying  out  this  plan 
great  care  must  be  taken,  lest  if  it  fail  and  vomiting 
occur,  the  ejected  matter  should  enter  the  windpipe. 
If  vomit  be  drawTn  into  the  trachea  and  cannot  be 
coughed  up,  it  may  be  necessary  to  open  that  tube 
and  to  take  measures  for  the  removal  of  the  foreign 
bodies  from  the  air  passages. 

Collapse. — When  it  is  necessary  to  administer  an 
anaesthetic  to  persons  already  collapsed,  and  ether  is 
selected  as  most  likely  to  assist  the  heart's  action,  it  is 
well  to  obviate  any  further  shock  from  difficulty  of 
breathing,  chilling,  &c,  by  removing  the  bag  from 
Clover's  regulating  ether  apparatus,  and  so  letting  the 
patient  inhale  a  very  dilute  ether  vapour.  Another 
plan  is  to  take  the  apparatus  off  the  face  during  the 
first  half  inspiration  as  well  as  during  expiration. 


After  Effects  of  Ether. 

Ether  chills  the  body,  so  that  when  the  anaesthesia 
has  to  be  kept  up  for  any  length  of  time  it  is  advisable 
to  keep  the  patient  well  covered  up,  and  to  apply  hot 
water  bottles  to  feet,  thighs  and  flanks.  The  arms  and 
legs  may  also  be  bound  up  in  cotton  wool  especially 
when  rectal  etherisation  is  contemplated.  It  has  been 
suggested  that  the  use  of  a  hot  water  table  for  pro- 
longed and  grave  operations  would  counteract  the 
shock. 


92  ANESTHETICS. 

Nausea  and  vomiting  in  some  cases  prove  trouble- 
some and  very  intractable.  They  usually  occur  in  per- 
sons whose  general  health  has  been  impaired  before 
receiving  the  anesthetic.  A\[  food  and  stimulants 
must  be  withheld  for  three  or  four  hours  after  ether, 
and  the  patient  be  encouraged  to  take  tea- spoonfuls  of 
hot  water ;  tepid  water  provokes  more  vomiting,  hot 
water  checks  it.  The  use  of  metal  spoons  in  so  ad- 
ministering the  water  should  be  avoided,  that  the  lips 
and  tongue  may  not  be  blistered.  In  some  cases  iced 
soda  water  in  sips  will  check  vomiting,  while  iced  black 
coffee  with  a  dose  of  bromide  is  often  efficacious  (gr.  x. 
to  a  small  cupful).  Absolute  quiet  with  an  enforcement 
of  the  supine  position  must  be  observed,  while  the 
patient  is  placed  in  an  airy  room,  with  windows  opened, 
and  well  covered  with  blankets  or  rugs.  In  lesser 
degrees  of  sickness,  sucking  pieces  of  ice  is  useful ;  but 
the  loading  of  the  stomach  with  ice-cold  water  is  a 
measure  often  followed  by  great  sickness  and  dis- 
comfort. 

Should  vomiting  continue  and  there  be  accompany- 
ing collapse,  iced  dry  champagne  may  be  given  in  tea- 
spoonful  doses  every  quarter  of  an  hour  until  improve- 
ment occurs. 

Some  persons  suffer  from  great  nausea  without  much 
sickness.  Small  doses  of  tincture  of  nux  vomica  will 
do  good  in  these  cases,  one  minim  in  a  tea- spoonful  of 
water,  by  preference  hot,  may  be  taken  every  ten 
minutes  for  an  hour.  This  will  usually  check  the 
nausea,  and  failing  it,  Dr.  Ringer's  suggestion  of  drop 
doses  of  vin.  ipecac,  may  be  tried.  Dilute  hydrocyanic 
acid  in  minim  doses  is  also  useful. 

Hiccough,  which  is  sometimes  very  severe  alter  ether, 


AFTEK    EFFECTS    OF    ETHER.  93 

maybe  cured  by  mustard  ( 3  j.  infused  and  added  to 
^  iv.  of  boiling  water)  taken  in  sips.  Less  unpleasant 
remedies  are  cajeput,  musk,  chloral,  and  morphine 
(administered  hypodermically).  A  small  cup  of  strong 
green  tea,  taken  hot  and  without  sugar  or  milk,  will 
often  check  hiccough. 

Diarrhoea,  and  passage  of  blood  per  anum  after  rectal 
etherisation  should  be  treated  by  emollient  injections 
containing  opium,  while  the  general  strength  of  the 
patient  be  attended  to,  and  his  collapse  treated  upon 
general  principles. 


94  ANESTHETICS. 


CHAPTER   V. 

Chloroform. 

Chloroform  (CHC13)  was  discovered  by  Mr.  Samuel 
Guthrie  of  Brimfield,  Massachusetts,  U.S. A  ,  who  con- 
tributed an  article  in  the  American  Journal  of  Science 
and  Art,  Oct.  1831,  upon  "  A  spirituous  solution  of 
chloric  ether."  This  paper  was  in  the  hands  of  the 
publisher  in  May  although  it  was  not  actually  published 
until  the  October.  In  January,  1832,  Soubeiran  inde- 
pendently discovered  chloroform,  but  as  on  analysis  he 
overlooked  the  presence  in  it  of  hydrogen,  he  called  it 
bichloride  of  ether.  Liebig  also  discovered  it  inde- 
pendently in  November,  1831,  and  classed  it  as  a  liquid 
chloride  of  carbon.  It  was  not,  however,  until  1834 
that  the  true  composition  of  chloroform  was  under- 
stood, and  its  properties  enunciated  by  Dumas.  As  is 
well-known,  its  employment  as  an  anesthetic  was  due 
to  the  advocacy  of  Sir  James  Y.  Simpson,  in  1847, 
after  its  having  been  introduced  to  his  notice  by  Mr. 
Waldie,  of  Liverpool. 

Chemical  and  physical  properties. — It  is  a  limpid  heavy 
liquid  with  a  specific  gravity  of  1-497  at  62-5°  F.  (17°  C.) 
(liegnault) ;  vapour  density  4*199  (Dumas).  It  has 
an  agreeable  ethereal  smell  and  sweet  taste.  Its  vapour 
is  not  easily  inflammable,  but  if  ignited  burns  with  a 
green  flame.  It  is  very  volatile,  but  although  mixing 
freely  with  air,  pure  chloroform  vapour  can  only  exist 
at  a  temperature  of  140°  F.      When  exposed  for  some 


CHLOROFORM.  95 

time  to  light,  chloroform  splits  up  into  chlorine  and 
hydrochloric  acid.  Chloroform  vapour  diffused  in  a  hot 
room  when  illuminating  gas  is  burning  splits  up  and  a 
quantity  of  suffocating  fumes  are  liberated.  It  boils  at 
about  142°  F.  (61°  C.)  (Kegnault).  To  test-paper, 
chloroform  should  be  absolutely  neutral.  Soluble  only 
to  the  extent  of  one-half  per  cent,  in  water  it  freely 
mixes  with  ether  and  alcohol. 

Chloroform  is  prepared  by  the  action  of  rectified 
spirit  on  chlorinated  lime  in  the  presence  of  slaked  lime. 
After  distillation  the  impure  product  is  refined  with 
water  which  removes  the  alcohol,  chlorine,  &c.  ;  oily 
matters  are  disposed  of  by  washing  with  sulphuric  acid, 
while  the  remaining  matter  is  eliminated  by  distillation 
over  dry  chloride  of  lime  and  slaked  lime. 

Chloroform  may  also  be  manufactured  from  methy- 
lated spirit ;  the  product  when  carefully  purified  is  said 
to  be  chemically  indistinguishable  from  that  obtained 
from  proof  spirit. 

A  further  source  of  chloroform  is  acetone.  The 
acetate  of  lime  is  carefully  distilled  and  purified, 
and  the  acetone  so  obtained  diluted  and  forced  into  a 
still  which  contains  chlorinated  lime  in  the  presence  of 
water.  The  mixture  is  kept  agitated,  crude  chloroform 
distilling  over.  Subsequent  purification  and  the  addi- 
tion of  a  small  quantity  of  alcohol  completes  the  pro- 
cess. The  reaction  may  be  represented  as  follows  : — 
2C3H60  +  6CaOCl2-2CCl3H+Ca(C2H302)2  +  2Ca(HO)2 

+  3CaCl2. 

A  further  process  consists  in  the  dry  distillation  of 
crude  acetate  of  lime  and  the  formation  of  chloroform 
from  crude  ketones  or  the  mixed  acetones  obtained  by 
this  distillation. 


96  ANESTHETICS. 

It  is  asserted,  however,  by  some  that  chloroform 
possesses  a  slightly  varying  physiological  action  ac- 
cording as  it  is  derived  from  one  or  the  other  source 
detailed  above. 

Chloroform  is  liable  to  contain  certain  impurities  :  — 
Alcohol. — This  must  be  present  in  a  small  quantity  in 
order  to  prevent  decomposition  of  the  chloroform.  The 
impurity  is  detected  firstly  by  the  specific  gravity*;  which 
below  1-48  points  to  adulteration,  probably  by  alcohol. 

Tests. — 1.  A  few  drops  of  the  doubtful  chloroform  are 
added  to  a  solution  of  white  of  egg,  and  if  alcohol  be 
present  to  the  extent  of  2  or  3  per  cent.  (Letheby),  the 
albumen  coagulates. 

2.  A  mixture  of  equal  parts  chloroform  and  almond 
oil  becomes  turbid  if  alcohol  be  present. 

3.  The  suspected  chloroform  is  dropped  into  distilled 
water  ;  if  containing  alcohol  the  otherwise  transparent 
globules  look  as  if  surrounded  by  a  milky  halo  of  opales- 
cence (Mialhe). 

4.  Chloroform  if  contaminated  with  alcohol  gives  a 
green  colour  with  chromic  acid. 

Ether  may  be  found  in  some  samples  of  chloroform, 
its  presence  being  revealed  by  its  odour  and  by  globules 
taking  a  dull- red  colour  with  iodine,  thus  contrasting 
with  the  violet  shade  which  pure  chloroform  gives. 
(Berchon). 

Crystallised  nitro-sodic  sulphide  of  iron  is  dissolved 
if  alcohol  or  ether  be  present  in  chloroform. 

Methyl  Compounds. — These  give  rise  to  nausea,  head- 
ache, lassitude ;  they  are  detected  by  adding  strong 
sulphuric  acid  to  the  chloroform,  which  becomes  black 
in  their  presence. 

Hydrochloric  acid  and  chlorine  are  liable  to  be  devel- 


PHYSIOLOGICAL    ACTION    OF    CHLOROFORM.  97 

oped  if  chloroform  be  exposed  to  light  and  air.  The 
first  gives  an  acid  reaction  ;  the  last  has  a  characteristic 
irritating  odour,  and  bleaches.  Suspected  chloroform 
may  be  shaken  with  distilled  water  and  this  tested  with 
nitrate  of  silver  for  chlorides.  The  presence  of  free 
acid  is  also  shown  by  adding  sodium,  which  in  contact 
with  the  acid  produces  an  evolution  of  gas.  It  is  useful 
to  remember  that  in  a  room  lighted  with  gas,  chloroform 
is  very  liable  to  undergo  the  above  decomposition,  noxi- 
ous fumes  being  liberated  which  may  prove  deleterious 
to  the  patient  and  seriously  inconvenient  to  the  operator. 
It  is  wise  to  ensure  thorough  ventilation,  and  as  little 
burning  of  illuminating  gas  in  the  presence  of  chloro- 
form as  possible. 

Physiological  Action  of  Chloroform. 

Upon  the  blood  corpuscles  this  substance  acts  as  a 
solvent.  It  is  a  protoplasm  poison  rapidly  destroying 
the  irritability  and  contractility  of  muscle. 

Prolonged  inhalation  of  chloroform  repeated  day 
after  day  for  a  considerable  time  is  said  to  lead  to  fatty 
degeneration  of  the  tissues,  and  it  is  further  asserted 
that  like  changes  occur  in  a  less  marked  degree  even 
when  but  little  of  the  narcotic  is  taken. 

Chloroform  behaves  somewhat  differently  according 
as  it  is  applied — (1)  to  the  skin  or  an  abraded  surface  ; 

(2)  to  the  mucous  membrane  of  the  alimentary  tract ; 

(3)  to  the  mucous  membrane  of  the  respiratory  tract. 
Tjfon  the  skin    and   abraded   surfaces    chloroform    be- 
numbs and  acts   as   a   strong  irritant.     If  the  contact 
be  prolonged,  and  if  evaporation  be  prevented,  vesication 
will  ensue.     It  is  therefore  important  to  guard  against 

h 


98  ANESTHETICS. 

these  effects  during  the  administration  of  chloroform,  by 
protecting  the  face  with  a  little  vaseline  smeared  over 
the  lips  and  nose. 

Upon  the  mucous  membrane  of  the  alimentary  tract. — 
"When  swallowed,  chloroform  produces  a  sensation  of 
warmth,  and  has  a  sweet  taste.  Anesthesia  follows  the 
swallowing  of  a  considerable  quantity,  but  other  and 
dangerous  symptoms  of  irritant  poisoning  are  provoked 
by  the  introduction  of  this  drug  into  the  stomach.  (See 
Medico-legal  Aspects  of  Ancesthetics,  Chap.  XII.).  Acute 
gistritis  and  death  from  collapse  have  in  some  cases 
followed. 

Chloroform  when  inhaled  produces  very  different 
effects  according  as  it  is  given  pure  or  diluted  with  air. 
Given  to  the  lower  animals  in  concentrated  vapour  (air 
saturated),  artificial  respiration  being  performed,  chloro- 
form soon  causes  the  right  ventricle  to  distend  and  be- 
come engorged,  the  heart  ceasing  to  beat.  Mc William 
has  demonstrated  experimentally  that  even  when  chloro- 
form vapour  is  diluted  it  produces  a  dilatation  of  all  the 
cavities  of  the  heart.  Up  to  a  certain  point  of  concen- 
tration, chloroform  vapour  will  not  permanently  damage 
the  resiliency  of  the  heart,  and  its  muscle  will,  upon 
withdrawal  of  the  narcotic,  contract,  while  the  ventricles 
and  auricles  resume  their  normal  size.  When  a  cer- 
tain point  of  concentration  is  reached,  however,  the 
myocardium  fails  to  contract  even  when  no  further 
chloroform  is  given,  and  rapidly  becomes  insensitive  to 
stimulation,  being  only  thrown  into  fibrillary  contrac- 
tion {delirium  cordis).  A  heart  once  so  dilated  beyond 
the  point  of  its  ability  to  re- contract  never  recovers  and 
the  creature  dies.  When  respiration  is  not  maintained 
by  artificial  means,  it  ceases  either  before  the  heart 


PHYSIOLOGICAL    ACTION    OF    CHLOROFORM.  99 

stops  or  simultaneously.  The  members  of  the  Hydera- 
bad Commission,  however,  came  to  conclusions  at 
variance  with  these  statements.  Their  investigations 
were  undertaken  in  India  and  carried  out  with  great 
care  and  skill,  a  large  number  of  animals  being  sub- 
jected to  experiment.  Their  results  may  thus  be 
summarised.  In  every  case  respiration  stopped  before 
the  heart,  the  interval  in  most  cases  between  the  two 
events  being  from  two  to  six  minutes,  although  it  was 
only  one  minute  in  some  instances,  and  in  one  case 
eleven  (in  a  dog),  in  another  twelve  minutes  (in  a 
monkey). 

On  the  other  hand  it  has  been  urged  that  the  conclu- 
sions at  which  the  Commission  arrived  are  open  to 
objection ;  since  in  the  first  place  their  experiments 
were  too  few  (600)  to  prove,  because  they  never  observed 
heart  failure  to  precede  cessation  of  respiration,  that 
therefore  primary  heart  failure  does  not  occur.  In 
the  second  place,  other  observers  working  in  temperate 
climates  affirm  they  have  repeatedly  met  with  primary 
heart  failure  among  the  lower  animals.  Dr.  Lawrie, 
supporting  the  conclusions  of  the  Commission,  states  he 
has  a  resord  of  about  40,000  cases  of  human  beings 
subjected  to  chloroform  in  none  of  whom  primary 
heart  failure  occurred,  indeed  he  met  with  no  case  of 
death.  Various  American  and  European  persons  of 
authority  traverse  this  by  pointing  out  the  fact  that 
in  temperate  climes  deaths  from  chloroform  inhalation 
occur  in  the  practice  of  the  most  skilled  anassthetists, 
and  that  such  deaths  have  been  repeatedly  observed 
to  have  resulted  from  primary  heart  failure.  I  have 
found  that  the  hearts  of  animals  killed  by  a  lethal  dose 
of  chloroform  show  fibrillary  irritability  for  some  time 

h  2 


100  ANESTHETICS. 

after  the  heart- muscle  as  a  whole  is  incapable  of  con- 
tracting in  response  to  electrical  or  mechanical  excita- 
tion. This  state  no  doubt  corresponds  to  the  condition 
called  by  Professor  McWilUam  "  delirium  cordis." 

The  various  parts  of  the  nervous  system  appear  to 
become  affected  in  the  same  order  as  obtains  in  the  case 
of  ether,  that  is  to  say  the  cerebral  centres  are  influ- 
enced before  the  sensory  fibres  of  the  cord,  and  these 
before  the  motor  fibres,  while  last  of  all  the  medulla 
becomes  paralysed.  It  therefore  would  seem  that 
chloroform  may  kill  in  two  ways  :  firstly  by  interfering 
with  the  heart's  action  and  so  inducing  syncope,  and 
secondly  by  paralysing  the  vital  centres  in  the  medulla. 
In  the  former  case  death  takes  place  early  in  the  narco- 
sis, but  in  the  latter  only  when  the  blood  is  saturated  to 
a  certain  (at  present  unknown)  point. 

Chloroform  seems  to  have  a  selective  action  upon  the 
nervous  system,  analysis  of  the  tissues  of  persons  who 
have  been  killed  by  chloroform  showing  that  the  brain 
and  cord  contain  proportionately  more  of  it  than  other 
tissues  (Lallemand,  Perrin  and  Duroy).  What  is  the 
nature  of  the  action  upon  the  nerve  centres  we  are  unable 
to  say,  but  evidence  points  to  the  probability  that  it  is 
exerted  upon  the  tissues  themselves.  Harley  and  others 
have  asserted  that  chloroform  produces  destructive 
changes  in  the  red  blood  corpuscles,  and  they  explain 
the  occasional  jaundice  following  chloroformisation  as 
arising  therefrom.  Others  have  believed,  but  upon 
insufficient  evidence,  that  chloroform  exerts  its  influ- 
ence by  changes  which  it  effects  in  the  process  of  oxida- 
tion. It  has  been  shown  that  chloroform  exercises  a 
direct  influence  upon  the  muscular  tissues  of  the  heart, 
although    voluntary    muscle   is    but    slightly   affected. 


PHYSIOLOGICAL   ACTION    OF    CHLOROFORM.  101 

Chloroform,  although  possibly  in  part  split  up  (Zeller), 
certainly  in  bulk  remains  unaltered,  and  is  eliminated 
unchanged  in  the  urine,  the  breath,  and  the  milk.  Its 
use  produces  a  marked  lowering  of  blood  pressure,  al- 
though this  may  be  preceded  by  a  very  transient  rise. 
The  fall  is  due  in  part  to  paralysis  of  the  vaso-motor 
system  as  has  been  shown  by  Bowditch  and  Minot,  and 
in  part  to  the  diminished  force  of  the  heart's  action, 
itself  a  result  of  the  chloroform.  Large  doses  of  chloro- 
form cause  the  heart  to  stop  at  once,  and  it  becomes 
absolutely  inexcitable.  It  is  doubtful  whether  arrest  of 
the  heart  be  due  to  direct  action  of  the  chloroform  upon 
its  substance,  or  to  reflex  inhibition  through  irritation 
of  the  nerve  endings  of  the  pneumogastrics  in  the 
lungs.  We  know  from  experiment  that  chloroform 
is  able  to  stop  the  heart  when  applied  directly  to  its 
substance,  and  we  know  further  that  it  actually  kills 
the  heart  muscle  and  destroys  its  contractility. 

With  regard  to  the  reflex  theory  above  mentioned,  it 
must  be  admitted  that  we  are  at  present  without  any 
actual  proofs  of  its  truth.  The  conclusions  of  the 
Hyderabad  Commission  upon  these  points  are  worthy 
of  notice.  They  assert  that  the  fall  of  blood-pressure, 
when  due  to  vagal  stimulation  brought  about  by  as- 
phyxial  conditions,  is  really  protective.  "  The  slowing 
of  the  heart  and  circulation  which  is  produced  by  irrita- 
tion of  the  vagus  by  any  cause,  such  as  holding  the 
breath  in  chloroform  administration,  retards  the  ab- 
sorption and  conveyance  ol  chloroform  to  the  nerve- 
centres." 

Chloroform,  as  has  been  previously  pointed  out,  acts 
upon  the  medullary  centres ;  presumably  each  indi- 
vidual can  take  a  certain  quautity  varying  according 


102  ANESTHETICS. 

as  be  is  capable  of  eliminating  the  drug,  and  when  tins 
quantity  is  exceeded,  the  respiratory  centre  becomes 
paralysed,  and  respiration  ceases  while  the  heart- beat 
persists  for  a  few  seconds  longer.  Taniguti,  working 
under  Salkowski,  found  that  chloroform  inhalation  or 
ingestion  by  the  mouth  produced  a  rise  in  the  excretion 
of  nitrogen  showing  increased  disintegration  of  albumen. 
No  such  effects  followed  when  ether  was  substituted  for 
chloroform . 

The  further  action  of  chloroform  upon  the  body  is 
slight;  it  produces  some  increase  in  salivary  secretion, 
and  in  small  quantity  excites  vomiting.  In  a  certain 
proportion  of  persons  it  provokes  icterus.  Astigmatism 
has  been  observed  as  following  the  narcotism  of  chloro- 
form. Albuminuria  and  glycosuria  are  also  recorded 
as  being  induced  by  this  agent. 


The  Human  Subject. 

In  describing  in  detail  the  action  exerted  by  chloro- 
form upon  the  human  subject,  it  is  convenient  to  divide 
the  period  of  narcosis  into  five  stages. 

In  the  first  stage — from  commencement  of  inhalation 
to  impairment  of  consciousness — fulness  of  the  head, 
ringing,  buzzing  in  the  ears,  and  palpitation  of  the 
heart,  are  sometimes  felt ;  there  is  also  some  diminu- 
tion of  common  sensation. 

In  the  second  stage  the  mental  powers  are  impaired 
although  not  suspended.  The  patient  remain 5  passive 
as  if  sleeping,  or  occasionally  makes  a  voluntary  move- 
ment. Sometimes  laughing,  singing,  talking,  are  in- 
dulged   in    during     this    stage.       Snow    believed    that 


THE    HUMAN    SUBJECT.  103 

dreaming  occurs  at  this  time  and  then  only.  Towards 
the  close  the  patient  becomes  restive,  he  attempts  to 
remove  the  face-iuece  or  towel,  for  he  is  conscious  of 
being  inconvenienced  by  the  vapour  but  not  of  the 
necessity  for  remaining  passive.  Common  sensation  is 
much  blunted,  so  that  patients  submit  without  expostu- 
lation to  painful  manipulation.  This  degree  of  narco- 
tism is  sufficient  for  obstetric  practice,  and  the  after 
stage  of  prolonged  operations.  As  a  rule,  struggles  or 
expressions  of  pain  which  show  themselves  at  this  time 
are  not  subsequently  remembered. 

In  the  third  stage  all  voluntary  movements  are  lost. 
The  conjunctival  vessels  become  full,  the  muscles  rigid, 
and  struggles,  even  epileptiform  convulsions,  may 
supervene.  As  the  stage  advances  the  muscles  relax, 
inarticulate  jabbering  and  mouthing  occur.  Although 
really  insensitive  to  pain,  the  patient  may  flinch  or 
even  cry  out.  Later  in  this  stage  all  reflex  acts  are 
abolished,  the  conjunctival  and  nasal  receding  last. 
The  patella  jerk  also  persists  late,  while  under  deep 
anaesthesia  the  ankle-joint  phenomenon  in  some  cases 
appears. 

In  the  fourth  stage  breathing  is  stertorous,  the  pupils 
dilated,  and  the  muscles  completely  relaxed  and  flaccid. 
At  this  period  the  patient  is  profoundly  unconscious  and 
is  drifting  into  danger.  Such  deep  narcosis  is  seldom 
needed  save  for  the  reduction  of  old- standing  disloca- 
tions, &c. 

The  fifth  stage  is  the  interval  which,  following  the 
fourth  degree  of  narcosis,  intervenes  between  the 
respiratory  embarrassment  and  total  cessation  of 
breathing.  Even  after  dyspnoea  has  passed  into  apnoea, 
the  heart  continues  to  beat  for  a  brief  while.     This 


104:  ANAESTHETICS. 

stage  marks  the  period  when  chloroform  tension  in  the 
blood  is  great  enough  to  paralyse  the  respiratory 
centres  in  the  medulla  oblongata. 

Chloroform  enters  the  blood  until  an  equilibrium  is 
established  between  the  tensions  of  chloroform  in  the 
residual  air  in  the  lungs  and  that  in  the  serum.  So 
long  as  the  tension  in  the  air  is  maintained  above  or 
equal  to  that  in  the  blood,  no  chloroform  can  leave  the 
serum  through  the  agency  of  the  pulmonary  mucous 
membrane.  Snow  demonstrated  this  theoretical  asser- 
tion by  actual  experiment  substantiating  the  truth  of 
the  a  priori  statement,  and  so  he  arrived  at  the  follow- 
ing law: — "As  the  proportion  of  vapour  in  the  air 
breathed  is  to  the  proportion  that  the  air,  or  the  space 
occupied  by  it,  wTould  contain  if  saturated  at  the 
temperature  of  the  blood,  so  is  the  proportion  of 
vapour  absorbed  into  the  blood  to  the  proportion  the 
blood  would  dissolve." 

The  amount  of  vapour  which  can  be  taken  up  (held 
in  solution)  by  the  air  of  the  atmosphere,  varies  with 
the  elastic  tension  of  the  chloroform  vapour  at  different 
temperatures.  Thus  at  40°  F.  a  small  quantity  of 
chloroform  would  evaporate  into  air ;  at  130°  F.  so 
much  would  volatilise  as  to  give  rise  to  an  almost  pure 
chloroform  vapour.  In  the  following  table,  taken  from 
Snow's  "  Anaesthetics,"  the  amount  of  chloroform  in 
vapour  is  shown  in  100  cubic  inches  of  saturated  mix- 
ture of  air  and  chloroform  at  different  temperatures. 

One  grain  of  chloroform  in  one  hundred  cubic  inches 
of  air  produces  the  second  degree  of  narcosis,  but  never 
carries  chloroformisation  further.  This  corresponds  to 
a  proportion  of  1  part  by  measure  of  chloroform  in 
10,280   parts   blood,  or  0*0000014   the  proportion  by 


THE    HUMAN    SUBJECT. 


105 


weight.  Two  grains  in  each  hundred  cubic  inches  of 
air,  or  J^  saturation  (unity  being  saturation),  produces 
the  fourth  stage  of  narcosis,  or  0*0001228  the  propor- 
tion by  weight. 

Any  proportion  above  two  grains  in  the  hundred 
causes  interference  with  respiration,  three  grains  in  the 
hundred  seems  about  the  ratio  which  renders  respira- 
tion  impossible.      Three   grains    represent   2  3    cubic 


egrees. 
F. 

40 

Air. 
per  cent. 

..     94     . 

Vapour. 
per  cent 

6 

45 

..     93     . 

..       7 

50 

..     92     . 

..       8 

55 

..     90     . 

..     10 

60 

..     88     . 

..     12 

65 

..     85     . 

..      15 

70 

..     81     . 

..     19 

75 

..     78     . 

..     22 

80 

...     74     . 

..     26 

85 

..     70     . 

..     30 

90 

..     65     . 

..     35 

inches  vapour,  and  as  air  at  100°  F.  can  take  up  43*3 
per  cent,  of  its  volume,  the  blood  must  contain  from 
Ts  ^°  tV  °f  ^ne  proportion  it  is  capable  of  absorbing 
when  the  respiratory  centres  are  poisoned. 

Snow  found  further,  that  calculating  the  weight  of  the 
blood  as  thirty  pounds,  twelve  minims  of  chloroform  in 
the  circulation  produces  narcosis  of  the  second  degree  ; 
eighteen  minims  the  third  degree  (surgical  anesthesia)  ; 
twenty- four  deep  narcosis  (fourth  stage),  and  thirty- six 
should  paralyse  the  medullary  centres.  Iu  practice 
more  is  needed  because  a  certain  proportion  evaporates 
from  the  tracheal  and  bronchial  surfaces  and  is  carried 


106  AX-ESTHETICS. 

out  in  expiration.  If  twelve  minims  be  evaporated  into 
a  bladder  and  inhaled  to  and  fro,  no  more  air  being 
allowed  than  can  be  blown  from  the  lungs,  narcosis  of 
the  second  degree  actually  results.  Now  taking  thirty- 
six  minims  as  a  lethal  dose,  the  following  considerations, 
upon  which  Snow  strongly  insisted,  explain  how  easily 
this  quantity  may  enter  the  circulation  if  the  adminis- 
trator be  not  perpetually  upon  his  guard  against  over 
dosage  ;  18  minims  represents  the  amount  absorbed  to 
produce  surgical  narcosis,  this  amount  might  be  ab- 
sorbed by  the  use  of  36  minims,  the  remaining  18 
minims  being  exhaled  as  above  mentioned.  These 
36  minims  represent  37*5  cubic  inches  of  vapour,  which 
at  60°  F.  would  require  257  cubic  inches  of  air.  The 
300  cubic  inches  thus  formed  would  be  inspired  in 
twelve  respiratory  acts  (25  cubic  inches  being  the 
amount  of  tidal  air).  Now  if  a  vapour  of  this  strength 
were  continuously  inhaled,  the  residual  and  comple- 
mental  air  would  become  saturated,  and  as  about  250 
cubic  inches  represents  the  air  in  the  lungs,  this 
amount  would  at  60°  F.  contain  the  vapour  of  30 
minims.  Assuming  only  half  this  quantity  to  be  ab- 
sorbed, that  is  15  minims,  we  should  then  have  18  -+-  15 
or  33  minims  in  the  blood,  an  amount  almost  if  not 
quite  enough  to  paralyse  the  respiratory  centre.  These 
points  being  held  in  remembrance  will  explain  many 
cases  of  chloroform  death,  ascribed  to  "  idiosyncrasy  " 
or  the  "fatty  heart"  which  stands  inexpert  chloro- 
formists  in  such  good  stead. 

These  considerations,  which  cannot  be  studied  too 
carefully,  point  out  the  importance,  not  only  of  taking 
precautions  against  giving  an  overdose  of  chloroform, 
but  the  equal  if  not   greater  importance  of  maintain- 


THE    HUMAN    SUBJECT.  107 

ing  a  completely  unimpeded  elimination  of  the  drug. 
The  Beports  of  the  Hyderabad  Commission  again  and 
again  urged  the  grave  dangers  which  follow  when 
asphyxia  (by  which  is  meant  impediment  to  thorough 
air  exchange  in  the  lungs)  is  even  in  the  slightest 
degree  permitted  to  complicate  chloroform  narcosis. 
Such  asphyxial  complications  of  course  mean  impaired 
elimination,  itself  tantamount  to  accumulation  of 
chloroform  in  the  blood.  Broadly  speaking  it  is  true 
to  say  that  a  dose  of  chloroform  which  is  safe,  provided 
due  air  exchange  is  ensured,  rapidly  grows  dangerous 
when  its  elimination  is  interfered  with.  Death  from 
chloroform  does  not,  however,  always  result  from 
respiratory  paralysis. 

Dr.  Lawrie  and  the  Hyderabad  Commissioners  on 
Chloroform  have  ably  traversed  the  work  of  previous 
investigators,  and  assert  most  positively  that  in  their 
view  primary  heart  failure  never  occurs  in  the  human 
subject  as  a  result  of  chloroform.  They  consider  their 
experiments  justify  them  in  stating  that  death  from 
chloroform  always  results  from  respiratory  failure,  and 
that  in  every  case  the  heart  beats  for  some  minutes 
after  the  complete  cessation  of  breathing.  These 
views  Dr.  Lauder  Brunton,  acting  as  assessor  for 
the  Lancet  during  the  second  Hyderabad  Commis- 
sion, appears  to  have  adopted,  basing  his  change  of 
opinion  upon  the  series  of  very  careful  and  beautiful 
experiments  at  which  he  himself  assisted.  It  would 
serve  no  useful  end  to  discuss  these  here :  I  may, 
however,  say  that  many  observers  contend  that  although 
pertinent  and  cogent  enough  as  far  as  they  go,  they 
cannot  be  said  to  have  substantiated  any  facts  proving 
the  non-occurrence  of  primary  heart  failure,  although 


108  AX.ESTHETICS. 

they  offer  weighty  arguments  tending  to  that  conclu- 
sion. The  research,  as  far  as  it  deals  with  the  question 
of  the  causation  of  respiration-failure  under  chloroform, 
has  placed  our  knowledge  upon  a  more  sure  basis. 

Working  on  similar  lines  to  Snow,  Paul  Bert  ex- 
amined the  action  upon  animals  of  small  percentages 
of  chloroform  vapour  in  air.  He  asserted  that  atmo- 
spheres containing  chloroform  below  a  certain  percentage 
failed  to  induce  anaesthesia  ;  below  a  higher  percentage 
(zone  maniable)  produced  anaesthesia  without  danger  to 
life,  even  when  a  vapour  of  this  strength  was  persisted 
in  for  an  indefinite  period ;  while  above  this  higher 
percentage  death  always  occurred.  The  lethal  per- 
centage he  found  to  be  double  the  smallest  quantity 
necessary  to  induce  anaesthesia.  Lister,  who  repeated 
Bert's  experiments,  found  no  true  zone  maniable  ("work- 
able zone  ")  to  exist.  Indeed,  the  French  observer 
appears  to  have  overlooked  the  important  fact  that 
chloroform  not  only  kills  by  paralysis  of  the  heart,  but 
also  by  failure  of  respiration.  Richardson,  whose  views 
seem  to  differ  from  those  who  adhere  to  the  percentage 
theory,  suggests  that  death  from  chloroform  is,  when  it 
occurs  in  the  latter  stage,  due  to  the  cumulative  action 
of  the  drug. 

Dr.  Kirk  of  Glasgow  has  recently  advanced  a  "  new 
theory  "  explaining  primary  cardiac  syncope  under 
chloroform.  He  contends  that  the  drug  acts  (1)  directly 
upon  the  mucous  membrane  of  the  lungs,  (2)  by  ab- 
sorption into  the  blood.  Accepting  the  second  mode  of 
action  as  that  which  ordinarily  obtains,  Dr.  Kirk  believes 
that  in  the  first  way  quite  a  similar  action  takes  place, 
and  that  it  readies  a  maximum  intensity  more  rapidly 
in  the  case   of   (2).     This  action  he   terms   the   "  ex- 


ADMINISTRATION    OF    CHLOROFORM.  109 

ternal,"  that  due  to  absorption  into  the  blood  as  the 
"  internal."  He  further  asserts  that  there  is  a  corre- 
sponding reaction  equal  and  opposite  to  both  this 
internal  and  external  action.  In  the  early  stage  of 
chloroformisation,  say  within  2i  minutes  or  so,  if  this 
external  action  ceases  by  the  withdrawal  of  the  chloro- 
form vapour,  then  a  rapid  and  vigorous  reaction  sets 
in  and  it  is  this  sudden  swirl  and  bound  of  the 
circulation  which  Dr.  Kirk  believes  gives  rise  to 
primary  cardiac  syncope.  Dr.  Kirk  insists  that  the 
Hyderabad  Commission  was  in  error  in  denying  prim- 
ary syncope,  and  believes  the  best  means  of  counter- 
acting its  danger  is  to  give  "plenty  of  chloroform" 
and  take  pallor  or  other  threatening  of  syncope  rather 
as  an  indication  for  more  chloroform  than  for  the 
withdrawal  of  that  drug. 


The  Administration  of  Chloroform. 

Various  as  are  the  methods  in  vogue  in  this  and 
other  countries,  they  may  with  propriety  be  grouped 
under  two  headings.  1.  When  an  inhaler  is  employed. 
2.  When  the  open  method  is  followed. 

Among  the  multitude  of  inhalers  which  have  been  de- 
vised, we  may  notice  Clover's  chloroform  appara- 
tus, which  consists  of  a  large  bag  capable  of  containing 
a  given  volume  of  air  ;  into  this  the  vapour  of  a  given 
quantity  of  chloroform  is  allowed  to  enter,  and  the 
mixture  is  so  arranged  that  the  tension  of  chloroform 
vapour  in  the  air  is  maintained  below  4*5  per  cent. 
The  bag  is  constructed  large  enough  to  hold  sufficient 


110  ANAESTHETICS. 

for  several  patients.  It  is  connected  at  one  end  by  a 
flexible  tubs  with  a  face  piece,  and  at  the  other,  with  a 
bellows  worked  by  the  foot.  To  the  bellows  is  attached 
a  small  metal  receiver,  into  which  a  known  quantity  of 
chloroform  is  pumped  by  a  graduated  syringe  inserted 
into  the  lid.  Forty  minims  of  the  narcotic  are  supplied 
with  every  thousand  cubic  inches  of  air  pumped  in, 
and  as  these  represent  forty-five  cubic  inches  of  vapour, 
the  percentage  of  chloroform  never  exceeds  about  4-^ 
per  cent. 

Chloroform   kills   by    concentration    of    its    vapour, 
hence  our  aim  in  its  administration  is  to  maintain  the 
amount  of  chloroform  in  the  respired  atmosphere  below 
the  dangerous  percentage  (five  per  cent.).     A  percent- 
age of  five  is  very  distinctly  lethal.     But  it  has  also  to 
be  borne  in  mind  that  chloroform  is  a  cumulative  drug, 
that  it   is   not  changed  during  its  passage  through  the 
body,  and  that  its  elimination  depends  upon  the  healthy 
working  state  of  the  emunctories,  more  especially  lungs 
and  kidneys.     Hence  the  percentage  of  chloroform  with 
which  we  start  will  be  unnecessarily  high  for  the  main- 
tenance of  anaesthesia  when  narcotism  is  once  affected, 
and  any  method  employed  which  hinders  free  expiration, 
or  hampers  chest  movements,  is  most  prejudicial  to  the 
safety  of  a  patient.     Yet  again,  persons  vary  so  largely 
in  their  resistive  power  towards   chloroform,  that  it  is 
impossible  to  feel  sure  that  a  percentage  which  would  be 
necessary  in  one  case  would  be  adequate  in  another. 
But  while  we   are  dealing  with  an  agent  which  is  ad- 
mittedly  dangerous  in  high  percentages,  one  is  apt  to 
rush  into  another  extreme,  and  allow  the  percentage  to 
fall  so  low  that  complete  anaesthesia  is  not  maintained. 
In  this  case  the  patient's  safety  is  as  much  in  jeopardy 


ADMINISTRATION    OF    CHLOROFORM.  Ill 

as  when  he  is  inhaling  too  concentrated  a  vapour.  It 
will  readily  be  seen  that  even  the  best  inhaler  may 
involve  many  risks,  as,  with  perhaps  the  exception  of 
Clover's,  none  can  absolutely  maintain  the  desired  per- 
centage. 

Snow's  Inhaler. — This  consists  of  a  metallic  cylin- 
drical vessel,  in  which  are  fastened  four  stout  wires 
descending  nearly  to  the  bottom,  which  fix  two  coils  of 
blotting  paper  going  quite  to  the  bottom.  The  coils 
are  cut  into  four,  and  are  thus  allowed  free  circulation 
of  air,  which  enters  through  perforations  in  the  upper 
part  of  the  cylinder.  Outside  this  part  of  the  ap- 
paratus is  another  cylinder,  which  is  filled  with  cold 
water ;  communicating  with  the  interior  a  glass  tube 
passes  to  the  outside  and  so  enables  the  administrator 
to  see  when  fresh  chloroform  will  be  required.  The 
face-piece  is  fitted  with  an  expiratory  and  an  inspira- 
tory valve,  which  last  communicates  with  a  f -inch  tube 
fixed  to  the  inhaler.  The  air  enters  through  perfora- 
tions in  the  upper  part  of  the  inhaler,  traverses  down 
through  the  notches  and  takes  up  chloroform  vapour 
volatilised  from  the  bibulous  paper,  thence  it  passes  up 
the  centre  of  the  inner  cylinder  into  the  tube  attached 
to  the  face- piece.  During  inspiratory  efforts  the  valve 
trapping  this  tube  permits  of  chloroform  vapour  enter- 
ing the  patient's  lungs,  while  during  expiration  this 
ingress  valve  closes,  and  the  patient  freely  evacuates 
his  lungs  through  the  expiratory  valve.  From  two  to 
two  and  a  half  drachms  of  chloroform  are  placed  in  the 
inhaler  at  once,  and  more  added  from  time  to  time  as 
this  evaporates. 

Sansom's    Inhaler. — Dr.    Sansom    has    modified 
Snow's  apparatus.     The  receiver  is   a  cylinder  3  in. 


112  ANESTHETICS. 

high  by  11  diameter,  filled  with  a,  coil  of  lint  upon 
which  the  chloroform  is  poured.  The  top  is  provided 
with  a  freely  perforated  plate  through  which  air  passes, 
to  become  impregnated  with  chloroform.  The  receiver 
communicates  by  an  exit  tube  with  a  face-piece  to 
which  are  attached  inspiratory  and  expiratory  valves. 
The  receptacle  is  covered  with  gutta  percha,  which 
Dr.  Sansom  believes  equalises  temperature  better  than 
the  cold  water  jacket  of  Snow. 

Junker's    Inhaler.— This  inhaler  (Fig.  24)  is  of 
value,  though  it  must  not  be   supposed  that  by  its  use 
the   patient   is   placed   outside    the   range    of  possible 
danger.     In  my  modification  of  this  apparatus,  half  an 
ounce  of  chloroform  is  poured  into  a  bottle  through  a 
funnel-shaped  opening  fixed  in  a  screw  top  ;   air  is  then 
pumped  through  the  chloroform,  and  in  its  passage  takes 
up  the  vapour.     The  foot  bellows  are  fixed  by  straps,  one 
of  which  slips  over  the  toes,  while  the  other  receives  the 
heel  in  the  long  loop.     "When  the  foot  presses  lightly, 
the  air  in  the  bellows  is   forced  through  the  tube  into 
the  bottle,  thence  through  another  tube  to  a  face-piece. 
The  net- enclosed  ball  is  for  equalising  the  stream  of  air 
and  the  avoidance  of  splashing.     It  is  important  not  to 
put  more  than  half  an  ounce  in  the  bottle  at  once,  and 
not  to  pump  in  air  spasmodically  or  too  forcibly,  other- 
wise chloroform  may  be  driven  through  the  system  of 
tubes   into    the   face-piece.     Even    if  this    should   not 
happen,  a  strong  blast  of  chloroform-impregnated  air 
is  very  unpleasant  and  deleterious  if  allowed  to  impinge 
upon  the   face.     \Vh<;ii   the  bottle  has  become  nearly 
empty,  the  mill-headed  stopper  which  closes  the  funnel 
is    removed    and     more    chloroform    added;     thus    the 
apparatus  need  never  be  unhooked  from   the   adminis- 


ADMINISTRATION    OF    CHLOROFORM. 


113 


trator's  coat,  and  the  top  never  unscrewed  until  the 
administration  is  over,  when  the  bottle  should  be  emp- 
tied and  cleaned. 


Fig.  24  — Junker's  Inhaler  for  chloroform,  modified  by  Dudley 

Buxton. 

When  chloroform  is  administered  for  operations  about 
the  mouth  or  nose,  e.g.,  removal  of  an  upper  jaw,  the 
tongue,  &c,  the  anaesthesia  having  been  obtained 
by  chloroform  is   best  maintained  by  fitting  the  effer- 


114  ANESTHETICS. 

ent  tube  of  a  Junker's  inhaler  (i.e.,  the  tube  not  con- 
nected with  the  bellows)  over  a  catheter,  and  either 
passing  the  catheter  through  the  nostril  so  that  the 
end  hangs  down  behind  the  soft  palate,  and  permits  the 
vapour  to  enter  the  larynx,  or  else  holding  the  catheter 
in  the  mouth.  When  a  preliminary  tracheotomy  has 
to  be  done  and  a  Trendelenburg's  or  Halm's  tube  is 
used,  the  catheter  may  be  held  over  the  external  open- 
ing of  the  tube,  and  chloroform  vapour  so  allowed  to 
enter  the  trachea. 

Another  plan  is  to  connect  the  tube  with  the  gag 
(Hewitt),  and  pump  the  vapour  into  the  mouth. 

This  inhaler  has  been  more  recently  greatly  improved 
by  Messrs.  Krohne  and  Sesemann,  the  original  makers. 
The  bottle  and  tube  remain  the  same,  but  in  the  latter 
an  obstruction  is  made  between  the  foot  or  hand  bellows 
and  the  bottle,  by  which  means  the  intermittent  jerky 
delivery  of  vapour  is  changed  to  a  continuous  supply. 
The  face-piece  is  replaced  by  a  Skinner's  mask  so  con- 
structed that  the  chloroform  vapour  escapes  by  a  series 
of  holes  in  the  midrib  of  the  frame.  The  frame  is 
covered  by  a  removable  flannel  cap.  By  this  contriv- 
ance the  face-piece  is  pervaded  with  vapour  instead  of 
a  puff  of  chloroform  being  intermittently  propelled 
against  the  face  as  in  the  old  apparatus.  The  advan- 
tages of  the  flannel  cap  are  its  permitting  free  breathing 
through  its  substance,  the  patient  obtains  a  free  air 
supply,  and  further  the  administrator  can,  by  placing 
his  hand  over  the  mask,  feel  whether  or  not  a  sufficient 
blast  of  air  is  being  expired.  It  is  cleanly,  as  it  can  be 
removed  easily  and  be  washed. 

The  same  firm  have  made  a  face  piece,  figured  below, 
which   is  provided  with  an  expiration  valve  guarded  by 


ADMINISTRATION    OF    CHLOROFORM. 


115 


a  stiff  feather.  This  rises  in  expiration,  falls  in  inspir- 
ation, and  affords  a  register  of  the  presence  and 
strength  of  expiration.     (Fig.  25). 

A  simple  inhaler,  much  used  abroad,  consists  of  a 
framework  of  wire  fitting  over  the  nose  and  mouth,  and 
covered  with  flannel.  Chloroform  from  a  drop  bottle 
is  allowed  to  fall  upon  this  while  the  patient  inhales 
from  the  concave   surface.     Although  convenient,  this 


Fig.  25. — Krohne  and  Sesemann's  Featlier  Respiration  Register. 

inhaler  is  far  from  safe  ;  it  has  no  pretensions  to  regu- 
lating the  percentage  of  vapour  it  allows  to  enter  the 
patient's  lungs,  and  so  must  be  used  with  the  utmost 
caution. 

A  cone  has  been  devised  by  Mr.  Krohne  and  figured  be- 
low (Fig.  26),  which  is  guarded  by  a  free  expiration  valve 
covered  with  the  feather  register  as  described  above. 
The  cone  is   simply   a  light  wire  netting  twisted  into  a 

i  2 


116 


ANESTHETICS. 


cone  and  covered  on  the  outside  by  red  flannel  perfor- 
ated by  a  circular  hole  for  the  dropping  in  of  the 
anaesthetic  employed.  The  interior  is  occupied  by  a 
flannel  bag  freely  removable  and  to  be  changed  for 
washing  whenever  desirable.  While  all  mechanical 
guards  to  inhalers  are  open  to  the  objection  that  they 
propose  to  replace  the  constant  watchfulness  of  the 
administrator  by  a  device  to  attract  attention,  yet  this 
feather  register  is  useful,  although  no  one  who  is  not 


Fig.  26. — Krohne  and  Sesemann's  Feather  Register  Cone. 

gravely  careless    would   trust   implicitly   to    any    such 
contrivance  however  ingenious. 

There  are  many  other  inhalers,  but  most  of  them 
contravene  the  first  law  of  giving  chloroform,  by  im- 
peding a  free  supply  of  air,  and  failing  to  regulate  the 
latter  to  the  proportion  of  chloroform  inhaled. 


The  Open  Method. 

Lister  thus  describes  the  Scotch  method : — A  common 
towel  is  arranged  so  as  to  form  a  square  of  six  folds, 


THE    OPEN    METHOD.  117 

and  enough  chloroform  is  poured  upon  it  to  wet  an 
area  the  size  of  a  hand's  palm,  the  precise  quantity 
poured  on  not  being  a  matter  of  any  consequence. 
The  patient  is  instructed  to  close  his  eyes  to  protect 
them  from  the  irritating  vapour,  and  the  towel  is  then 
held  as  near  to  the  face  as  can  be  borne  without  incon- 
venience. More  chloroform  is  added  from  time  to  time 
as  occasion  requires. 

A  piece  of  ordinary  lint  20  inches  square  and  folded 
in  four  so  that  the  fluffy  side  is  inwards,  serves  well  for 
the  exhibition  of  chloroform,  which  should  be  freely 
poured  upon  it.  If  necessary,  a  towel  may  be  held 
outside  the  lint,  but  on  no  account  must  it  be  permitted 
to  interfere  with  the  patient's  free  respiration. 

I  have  found  it  best  to  commence  the  inhalation  with 
a  comparatively  small  quantity  of  chloroform  upon  the 
towel,  especially  in  dealing  with  children.  In  a  minute 
or  so  the  sensibility  to  the  irritating  vapour  is  deadened, 
and  the  strength  of  the  atmosphere  may  be  increased. 
As  soon  as  unconscious  struggling  appears,  the  nar- 
cotic must  be  pushed,  as  danger,  such  as  exists  dur- 
ing the  stage  of  excitement,  is  due  to  the  muscular 
perturbation,  and  the  sooner  it  is  overpowered  the  less 
is  the  patient's  peril.  When  the  towel  is  withdrawn 
for  additional  chloroform  it  should  be  quickly  replaced. 
But  as  the  vapour  then  given  off  will  be  increased 
in  percentage  amount,  and  as  the  fresh  air  entering 
the  lungs  during  the  withdrawal  of  the  towel  may 
induce  a  deeper  inspiration,  it  is  well  to  keep  it 
a  trifle  farther  from  the  face  for  a  minute  or  so. 
Throughout  chloroformisation  the  respiration  must  be 
constantly  watched,  both  by  regarding  the  regularity  of 
*-;he  rhythm  of  the  thoracic  movements,  and  by  testing 


118  ANESTHETICS. 

lie  amount  of  air  passing  from  the  trachea.  Thoracic 
movements  persist  for  some  minutes  after  occlusion  of 
the  larynx  or  trachea,  and  so  hy  themselves  are  no  just 
criterion  that  sufficient  air  is  entering  the  lungs.  The 
pulse  should  be  observed,  for  not  only  may  the  heart 
fail  from  chloroform  depression,  but  from  haemorrhage, 
shock,  fear,  &c.  When  the  exigencies  of  the  operation 
allow  it,  the  head  should  be  quite  low,  supported 
by  one  small  pillow.  This  arrangement  should  be 
made  after  the  first  stage  of  narcosis,  because  patients 
while  conscious  like  to  have  their  heads  pretty  high. 
Fitness  for  operation  is  to  be  judged  by  the  loss  of  con- 
junctival reflex.  To  ascertain  this,  the  eyelids  are 
gently  opened,  and  the  cilia  lightly  touched  with  the 
palm  of  the  forefinger ;  should  no  blinking  occur,  the 
operation  may  be  commenced.  To  this  rule,  children 
and  hysterical  females  form  exceptions.  They  will  often 
permit  this  test  without  flinching,  but  will  evince  lively 
evidence  of  consciousness  if  the  unwary  administrator 
permits  surgical  manipulation  to  proceed.  The  deep, 
almost  stertorous  breathing,  the  muscular  rigidity  or 
complete  flaccidity  of  muscles,  will  in  these  cases  help 
out  the  diagnosis.  On  the  other  hand,  I  have  observed 
in  some  persons,  especially  if  afflicted  with  conjunc- 
tival or  ocular  disease,  that  the  conjunctival  reflex 
persists  for  some  time  after  complete  anaesthesia  has 
supervened.  The  size  and  mobility  of  the  pupils,  al- 
though somewhat  uncertain  in  their  indications,  should 
yet  be  observed.  In  surgical  anaesthesia  by  chloroform 
they  are  of  normal  size  and  usually  sensitive  to  light, 
dilating  however  during  emergence  from  narcosis,  and 
especially  before  vomiting  is  imminent.  But  sudden 
dilatation  also  occurs  when  the  patient  has  taken  an 


THE    OPEN    METHOD. 


119 


over- dose  and  the  heart  is  dangerously  depressed.  To 
distinguish  between  these  states  needs  the  utmost 
caution.  In  the  last  condition  deep  narcosis  and  its 
signs  will  exist,  the  pulse  will  be  almost  imperceptible, 
and  the  respiration  hampered ;  while  in  the  first,  the 
patient  will  give  unmistakeable  signs  of  returning 
consciousness,  which  may  be  accompanied  by  a  flag- 
ging pulse.  When  dilatation  of  the  pupil  results  from 
over-dosage,  measures  to  effect  restoration  must  at 
once  be  applied,  but  when  due  to  returning  conscious- 
ness, a  fresh  supply  of  chloroform  will  prevent  vomit- 
ing, steady  the  pulse,  and  cause  the  pupils  to  return  to 
their  normal  size.  This  must  be  done  boldly  but  very 
warily.  If  the  patient,  in  spite  of  all  efforts  to  prevent 
him,  should  vomit,  and  especially  if  it  be  known  that  he 
has  partaken  of  solid  food  within  the  last  two  or  three 
hours,  the  head  must  be  turned  aside  and  free  egress 
given  to  the  vomited  matter,  and  if  necessary  the 
mouth  must  be  cleared  with  the  finger.  The  danger 
to  be  avoided  in  this  contingency  is,  lest  the  vomit  be 
sucked  back  into  the  larynx  when  the  patient  makes 
the  strong  inspiration  which  always  follows  vomiting. 

When  the  dilated  pupil  signals  heart  failure  and 
cessation  of  respiration,  all  the  signs  of  increasing  and 
profound  narcosis  are  present,  and  then  it  is  that  the 
chloroform  must  be  removed  and  efforts  promptly  made 
to  restore  consciousness  and  stimulate  reaction  (see 
Treatment  of  Complications  under  Chloroform). 

During  the  progress  of  the  operation,  attention  should 
be  paid  to  the  condition  of  the  pupil  as  above  noticed, 
and  to  the  pulse  and  respiration. 

Although  heart  failure  may  occur  at  any  time  during 
chloroformisation,  it  is  more  liable  to  do  so  quite  at 


120  ANAESTHETICS. 

the  commencement ;  •while  more  danger  arises  subse- 
quently from  failure  of  respiration  through  accumu- 
lation of  chloroform  in  the  blood,  and  paralysis  of  the 
medullary  centres.  Weak  pulse  and  shallow  irregular 
breathing  may  indicate  over-dosage,  and  then  the 
amount  of  chloroform  given  must  be  diminished.  The 
colour  of  the  patient's  face,  lips,  and  ears,  is  a  valuable 
guide  to  his  condition  ;  lividity,  cyanosis  and  pallor, 
are  all  indications  that  danger  is  present.  The  opera- 
tion completed,  the  patient  should  still  be  carefully 
watched  until  he  has  recovered  consciousness  suffi- 
ciently to  prevent  accidents,  e.g.,  dropping  back  of  the 
tongue,  vomiting,  &c.  If  possible,  it  is  best  to  allow 
him  to  sleep  off  the  effects  of  chloroform,  and  it  is 
always  a  mistake,  unless  there  be  some  very  good 
reason,  to  arouse  a  chloroform  patient  from  his  doze  by 
loud  speaking,  shaking,  putting  water  on  his  face,  &c. 
Such  procedure  often  induces  vomiting  and  headache. 

Exception  has  been  taken  to  the  open  method  upon 
the  ground  that  it  is  impossible  to  regulate  the  amount 
of  chloroform  inhaled  and  so  to  obtain  a  definite  per- 
centage vapour  ;  also  because  so  much  vapour  escapes 
from  the  surface  of  the  towel  into  the  room  and  pre- 
judicially affects  onlookers.  Dealing  with  these  objec- 
tions, Sir  Joseph  Lister  has  found  after  careful  and 
ingenious  experimentation  that  only  sufficient  chloro- 
form escapes  from  the  lower  surface  of  the  towel  to 
constitute,  when  mixed  freely  with  the  circulating  air, 
an  atmosphere  of  4*5  per  cent.,  and  of  this  only  a  por- 
tion would  enter  the  patient's  lungs.  He  further  be- 
lieves that  inspiration  does  not  affect  the  rate  with 
which  evaporation  occurs.  Of  course  these  statements 
are  only  true  as  long  as  the  open  method  is  conducted 


METHOD    OF    DEFINITE    MIXTURES.  121 

strictly,  and  with  every  precaution  given  in  the  pre- 
ceding sections. 

Sir  Joseph  Lister  suggests  the  following  simple  way 
of  devising  a  chloroform  mask :  the  corner  of  a  towel 
pursed  up  systematically  into  a  concave  mask  to  cover 
the  mouth  and  nose  by  pinching  it  together  at  such  a 
distance  from  the  corner  that  when  the  pinched  up 
part  is  held  over  the  root  of  the  nose,  the  corner  ex- 
tends freely  to  the  point  of  the  chin.  "  The  cap  formed 
in  this  manner  being  so  arranged  upon  the  face,  chloro- 
form is  gradually  dropped  upon  it  till  the  greater  part 
of  it  is  soaked,  the  edges  being  left  dry  to  avoid  irrita- 
tion of  the  skin  by  the  liquid,  and  the  moist  condition  is 
maintained  by  frequent  dropping  on  the  convex  surface 
until  the  requisite  physiological  effects  are  produced." 

Hypodermic  injections  of  chloroform  have  been  sug- 
gested as  a  means  of  producing  anaesthesia,  but 
(Dujardin-Beaumetz)  they  fail  to  induce  general  nar- 
cosis while  affecting  some  local  anaesthesia.  This 
method  is  not  free  from  danger  as  (Bouchard  and 
Laborde)  it  has  been  shown  that  albuminuria  and  death 
have  in  the  lower  animals  resulted  from  its  use. 


Method  of  Definite  Mixtures. 

Clover  was  one  of  the  first  to  insist  upon  the  import- 
ance of  using  definite  mixtures  of  chloroform  vapour  in 
air,  and  his  apparatus  described  above  was  an  attempt 
to  bring  the  method  within  the  range  of  practical  anaes- 
thetics. P.  Bert,  however,  studied  the  subject  from  the 
experimental  side,  and  we  owe  to  him  much  of  our 
knowledge  upon  the  matter.  Although  successfully 
employed  by  Pean,  the  method  requires  too  cumber- 
some an  apparatus  to  be  used  save  in  hospitals. 


122  anesthetics. 

Complications    arising   during    the    Administration  of 
Chloroform,  and  their  Treatment. 

Syncope. — Failure  of  the  heart  may  occur  quite  at 
the  commencement  of  the  administration,  that  is,  after 
two  or  three  inspirations  of  chloroform  vapour,  or  it 
may  supervene  much  later — in  the  third  stage.  In  the 
primary  stage,  sjmcope  has  been  variously  accounted 
for ;  it  has  been  attributed  to  reflex  inhibition  of  the 
heart  excited  by  terror,  or  by  the  irritation  by  the 
chloroform  vapour  of  the  sensory  nerves  of  the 
pharyngo-laryngeal  mucous  membrane  and  pulmonary 
tract ;  or  to  an  individual  obnoxiousness  to  chloroform 
vaguely  called  the  chloroform  idiosyncrasy.  Cases  have 
been  recorded  of  sudden  death,  provoked  by  fear,  in 
persons  about  to  be  operated  upon,  who  have  either 
taken  no  anaesthetic  or  have  imagined,  erroneously, 
they  were  being  chloroformed,  while  in  reality  they 
were  inhaling  eau-de-Cologne,  or  an  equally  innocuous 
substance.  It  is  unquestionably  highly  important  that 
all  perturbing  causes  provocative  of  fear,  such  as  loud 
and  technical  talking  descriptive  of  the  horrors  of  the 
operation,  should  in  the  patient's  presence  be  carefully 
avoided.  No  movement,  such  as  uncovering  the  dis- 
eased area,  suggestive  of  the  commencement  of  the 
operation,  should  be  permitted  until  unconsciousness  is 
well  established.  Fear  and  trepidation  must  always  be 
met  by  kindly  re-assurance,  while  haste  and  brusque 
handling  must  be  studiously  avoided.  Nothing  can  be 
more  prone  to  produce  fatal  syncope  than  the  com- 
mencement of  the  operation  before  complete  anaesthesia 
bus  been  induced,  for  here  we  have  a  lowering  of  the 
vital  functions  caused  by  chloroform,   and   the   shock 


TREATMENT    OF    COMPLICATIONS.  123 

of  cutting  the  skin,  especially  over  a  sensitive  area, 
communicated  along  sensory  nerves  whose  conduction 
is  not  yet  in  abeyance.  Records  of  death  under  these 
circumstances  (incomplete  anaesthesia),  show  how  often 
the  fatality  arises  in  cases  when  trivial,  although  pain- 
ful operations,  such  as  reduction  of  dislocated  limbs, 
circumcisions,  &c,  are  performed.  Under  these  cir- 
cumstances, too,  it  must  be  remembered  that  the  heart 
is  peculiarly  liable  to  reflex  inhibition,  as  vasomotor 
paralysis  occurs  antecedently  to  loss  of  conduction 
along  the  sensory  tracts  of  the  nerves  and  cord. 

Symptoms.— Fluttering  feeble  pulse,  sudden  stop- 
page of  the  heart,  extreme  and  ghastly  pallor,  with 
blueness  of  the  ears  and  finger-tips,  wide  sudden  dila- 
tation of  the  pupils,  and  cessation  of  respiratory  move- 
ment, usher  in  this  syncope.  There  is  little  or  no 
warning  of  the  onset  of  this  heart  failure,  nor  can  the 
most  careful  preliminary  examination  give  an  indica- 
tion of  cases  in  which  it  is  likely  to  occur.  Persons  the 
subjects  of  fatty  degeneration  of  the  heart,  of  aortic  or 
advanced  mitral  disease,  are  of  course  always  liable  to 
syncope,  but  the  robust  and  vigorous  incur  a  like  risk, 
and  are  frequently  the  victims  of  syncope  occurring  in 
the  initial  stage  of  taking  chloroform.  Syncope  arising 
at  other  stages  of  chloroform  narcosis  commonly  gives 
more  warning  ;  there  is  a  gradual  failing  of  the  heart, 
evidenced  by  weakened  and  often  intermittent  pulse, 
pallor  and  cyanosis,  cessation  of  haemorrhage,  and  dila- 
tation of  the  pupils. 

Treatment. — Chloroform  must  be  at  once  removed, 
the  table  tilted  so  that  the  head  lies  at  a  lower  level 
than  the  feet,  and  when  possible,  the  legs  should  be 
raised,  so    assisting  a  return  of  blood  to   the   heart. 


124  ANESTHETICS. 

Complete  inversion  of  the  patient  as  practised  by 
Nelaton  is  certainly  the  most  important  remedial 
measure  we  possess,  but  should  never  be  employed 
when  asphyxial  complications  co- exist  with  the  syn- 
cope. The  respiration,  which  will  have  ceased  conse- 
quently upon  the  cessation  of  the  heart's  action,  must 
be  kept  up  by  the  artificial  methods  of  Howard  and 
Sylvester  (see  Chap.  X.).  When  the  thorax  is 
grasped  in  expiration,  it  is  well  to  slip  the  hand  under 
the  costal  border  on  the  left  side,  and  so  mechanically 
excite  the  heart.  The  chest  and  throat  bared  of  all 
clothing,  should  be  slapped  with  a  towel  wetted  in  cold 
water,  and  fresh  air  from  an  open  window  allowed  free 
access  to  the  patient.  The  injection  of  brandy  in  hot 
beef  tea  by  the  rectum,  and  hypodermic  injection  of 
ether,  or  failing  that,  whiskey,  especially  over  the 
prsecordium,  should  be  promptly  tried. 

The  inhalation  of  nitrite  of  amyl  is  vaunted  as  a 
specific,  and  certainly  in  cases  of  syncope  occurring  late 
in  narcosis,  or  after  an  operation  when  much  blood- 
loss  has  occurred,  I  have  seen  it  do  good.  The  most 
convenient  way  of  using  the  drug  is  to  smash  a  Uliij. 
glass  capsule  and  hold  it  beneath  the  patient's  nose, 
taking  care  that  artificial  respiration  is  maintained  so 
as  to  ensure  the  due  entrance  of  the  fumes  into  the 
lungs. 

Among  other  measures  advocated  for  counteracting 
this  syncope  must  be  mentioned  electrical  stimula- 
tion of  the  heart,  and  acupuncture  of  that  viscus. 

One  electrode  is  placed  over  the  neck  behind  the 
sternomastoid  at  about  the  juncture  of  its  lower  and 
middle  thirds,  while  the  other  is  wiped  over  the  prae- 
cordium.     I  am  not  prepared  to   say   that  this  step  is 


ASPHYXIA    FROM    CESSATION    OF    RESPIRATION.  125 

not  more  likely  to  produce  inhibition  than  excitation 
of  the  heart  muscle ;  by  stimulating  the  diaphragm 
to  contraction,  it  may  possibly  aid  respiration.  Acu- 
puncture of  the  ventricle  with  a  gold  needle  is  be- 
lieved to  act  by  exciting  that  viscus  to  contract  through 
direct  mechanical  stimulation. 

Syncope  arising  late  in  the  course  of  an  exhausting 
operation  must  be  met  by  the  above  methods  of  treat- 
ment, and  as  soon  as  the  patient  has  rallied  sufficiently 
to  be  able  to  swallow,  brandy  must  be  rubbed  over 
tongue  and  gums,  and  when  capable,  the  patient  should 
swallow  sips  of  brandy  in  hot  strong  beef  tea,  while 
sinapisms  are  applied  over  the  prascordium,  epigastrium, 
and  calves  of  the  legs.  The  head  must  be  kept  low,  and 
any  attempt  at  sitting  up  interdicted.  Eeaction  must 
also  be  aided  by  hot  water  bottles  applied  to  the  feet 
and  sides,  and  the  flow  of  venous  blood  be  promoted  by 
firm  rubbing  of  the  limbs  from  the  feet  and  hands 
towards  the  trunk.  Inversion  of  the  body,  so  that  the 
feet  are  in  the  air,  is  often  of  signal  service  in  extreme 
cases  of  cardiac  weakness,  when  there  is  no  reason  to 
believe  that  the  right  heart  is  engorged. 


Asphyxia  from  Cessation  of  Respiration. 

This  may  result  from  (1)  Mechanical,  (2)  Vital 
Causes. 

Mechanical. — Sir  Joseph  Lister  has  shown  that 
one  of  the  most  usual  and  dangerous  accidents  which 
occur  under  chloroform  is  occlusion  of  the  larynx  by 
the  folding  together  of  the  arytaeno-epiglottidean  folds 
so  that  their  posterior  portions  approximate,  and,  by 


126  ANESTHETICS. 

closing  upon  the  base  of  the  epiglottis,  prevent  any 
entrance  of  air.  This  accident  is  usually  evidenced  by 
stertor  and  irregular  respiratory  movements,  but  it  may 
supervene  without  any  such  warning,  and  as  the  chest 
movements  continue  may  be  overlooked.  If  permitted 
to  go  unrelieved,  the  impeded  breathing  reacts  unfavour- 
ably upon  the  heart,  already  depressed  by  the  chloro- 
form ;  cardiac  rhythm  is  impaired  or  checked,  and  the 
ghastly  aspect  of  the  patient  draws  attention  to  his 
danger. 

Treatment.— By  seizing  the  tongue  with  forceps, 
(Lister  employs  ordinary  artery  forceps  for  this  pur- 
pose"), and  dragging  it  somewhat  forcibly  out  of  the 
mouth,  the  obstructing  portions  of  the  arytaeno-epiglot- 
tidean  folds  are  caused  to  recede  from  the  epiglottis, 
and  so  leave  a  free  air-passage.  This  manoeuvre  acts, 
it  is  believed,  reflexly,  and  not  merely  mechanically. 

The  Tongue  may  fall  back  and  so  occlude  the 
laryngeal  opening.  When  the  patient  is  deeply  under 
the  anaesthetic,  the  hyoid  bone  drops  and  the  tongue  is 
carried  back  so  as  to  close  the  laryngeal  chink.  The  air 
is  thus  prevented  from  entering,  as  every  inspiratory 
effort  only  sucks  back  the  epiglottis,  which  acts  as  a 
valve  permitting  some  expiration  but  no  inlet  of  air. 
The  thoracic  movements  continue  even  when  this  acci- 
dent effectually  prevents  the  entrance  of  air.  Usually, 
but  not  always,  snoring  stertor  is  present  under  these 
circumstances. 

The  signs  of  asphyxia  soon  reveal  themselves,  the 
face  becoming  dusky,  then  blue,  and  finally  a  mottled 
black,  the  pulse  weakens,  and  unless  promptly  relieved, 
the  patienl  dies. 

Treatment. — To  prevent  this  accident,  the  chloro- 


FOREIGN    BODIES    IN    THE    LARYNX.  127 

formist  should  keep  a  finger  beneath  the  patient's  chin 
so  as  to  check  falling  down  of  the  hyoid  bone.  To 
remedy  the  clanger,  it  is  necessary  to  pull  forcibly  for- 
ward the  tongue,  using  forceps,  and  turning  the  head 
to  one  side,  so  that  the  weight  of  the  organ  shall  not 
carry  it  backward.  If  the  accident  has  not  been  noticed 
until  respiration  has  ceased,  it  will  be  necessary  besides 
the  directions  given  abo\e,  to  perform  artificial  respira- 
tion ;  but  usually  forcibly  compressing  the  thorax  once 
or  twice  is  all  that  is  needed. 

Mucus  sometimes  collects  over  the  upper  opening 
of  the  larynx,  and  in  persons  whose  respiratory  efforts 
are  not  vigorous,  may  cause  suffocation.  Insufficient 
air  exchange  leads  to  signs  of  asphyxia  more  or  less 
pronounced,  the  most  striking  of  which  is  the  pro- 
gressive duskiness  of  hue.  In  this  case  the  throat 
should  be  sponged  out  and  the  chin  jerked  up,  a  man- 
oeuvre often  sufficient  to  dislodge  the  pellet  of  mucus 
and  restore  normal  respiration. 


Entrance  of  Foreign  Bodies  into  the  Larynx  or 

Trachea. 

Teeth,  natural  or  artificial,  portions  of  bone,  blood 
clot,  masses  of  new  growth,  gags,  sponges,  are  liable 
to  drop  back  and  enter  the  air-passages,  or  become 
jammed  in  the  oesophagus  and  so  provoke  asphyxia  by 
mechanical  pressure.  Small  or  soft  substances  which 
enter  the  larynx  may  set  up  spasm  and  so  prevent  pas- 
sage of  air,  or  they  may  pass  into  the  trachea,  with 
the  same  result.  When  suffocation  can  be  attributed 
to  this  cause  its  relief  must  at  once  be  obtained  by  per- 


128  ANESTHETICS. 

forming  tracheotomy,  and  by  sucking  out  blood,  clots, 
masses  of  growth,  &c.° 

It  is  in  all  cases  necessary  to  examine  the  buccal 
cavity,  and  if  any  foreign  body  be  found  loose  it  must 
be  duly  removed  by  the  fingers  or  forceps. 

Inversion  is  also  of  value  in  cases  where  it  is  feared 
that  blood  has  entered  the  windpipe.  After  trache- 
otomy, sucking  the  tube  is  useiully  supplemented  by 
inversion. 

Insufflation  of  the  lungs  by  means  of  a  catheter 
passed  through  the  larynx  has  been  recommended,  but 
it  would  appear  less  effectual  than  tracheotomy  and 
artificial  respiration,  aided  when  need  be  by  sucking 
out  blood  or  mucus  from  the  tracheal  opening. 

Vital. — Asphyxia  may  result  from  over-dosage  ;  the 
respiratory  centre  becomes  paralysed,  the  movements  of 
respiration  grow  more  and  more  shallow,  and  at  last 
cease.  The  heart  ceases  to  beat  a  few  seconds  after 
breathing  has  stopped. 

Treatment. — Artificial  respiration  must  at  once  be 
practised. 

Epileptic  Fits  may  be  provoked  by  chloroform  in 
persons  subject  to  such  seizures  ;  they  usually  appear 
in  the  third  stage  of  narcosis. 

Hysterical  seizures  also  occur,  but  they  usually 
appear  in  the  second  stage. 

*  An  instructive  case  occurred  under  my  charge  at  University 
College  Hospital.  A  man  from  whom  the  upper  jaw  had  been  re- 
moved by  Mr.  Heath  was  under  operation  for  a  recurrence  of  epithe- 
liomatous  growth,  when  his  respiration  puddenly  became  hampered, 
and  signs  of  impending  suffocation  appeared.  Tracheotomy  was 
promptly  performed,  the  tube  sucked,  and  several  small  masses  of 
the  growth  withdrawn  from  the  windpipe  in  this  way.  The  man's 
breathing  was  restored  and  the  operation  was  completed. 


AFTER-EFFECTS    OF    CHLOROFORM.  129 

The   treatment   is    simply    that   of    preventing   the 
patients  from  injuring  themselves. 

(See  also  Chapter  on  Accidents  of  Anaesthesia). 


After-effects  of  Chloroform. 

Vomiting. — By  attention  to  the  directions  given 
above  (Chap.  II.),  vomiting  is  rendered  less  liable  to 
occur.  The  following  further  directions,  if  duly  carried 
out,  will  tend  to  the  same  end.  If  bilious  plethoric 
persons  have  their  bowels  well  cleared  before  taking 
chloroform  they  are  less  liable  to  sickness.  The 
patient's  head  should  be  kept  quite  low  ;  he  should  not 
be  moved  from  the  operating  table  for  half  an  hour 
after  coming  to  himself,  and  then  the  utmost  care  must 
be  taken  to  prevent  his  being  shaken  or  his  head  raised. 

Opium  should  not  be  given  by  the  mouth ;  and  unless 
there  is  obvious  and  urgent  shock,  brandy,  ether,  and 
sal  volatile  must  be  withheld.  No  food  must  be  allowed, 
whether  liquid  or  solid,  for  at  least  three  hours  after 
chloroforming,  and  then  nothing  warm  should  be  taken 
until  all  nausea  has  vanished.  Meat  jelly,  bread  boiled 
in  milk,  to  which  a  pinch  of  bicarbonate  of  soda  is 
added,  or  sponge  cakes  soaked  in  a  light  dry  sherry, 
may  be  permitted  after  this  time  ;  tea,  coffee,  soaked 
toast,  may  be  tried,  but  all  indigestible  or  solid  food 
should  be  denied  until  the  following  day. 

(For  the  medical  treatment  see  After-effects  of  Ether, 
Chap.  IV.). 

Hysteria.  —Fits  of  hysterics  are  sometimes  excited 
in  the  neurotic,  by  chloroformisation  ;  no  specific  treat- 
ment need  be  adopted.    These  attacks  seldom  last  more 

K 


130  AN.ESTHETICS. 

than  three  or  four  hours,  and  should  cause  no  alarm. 
They  may  occur  in  either  sex. 
Jaundice  and   general  biliary   derangement 

in  some  instances  follow  chloroform  administration. 
They  should  be  treated  upon  general  principles,  and 
need  give  rise  to  no  alarm. 

Albuminuria  and  glycosuria  of  a  transient  and 
unimportant  character  may  in  rare  cases  follow  the  use 
of  the  drug. 

Astigmatism,  giving  rise  to  fear  lest  the  sight  be 
permanently  injured,  has  been  noticed,  but  it  is  doubt- 
ful how  far  we  should  attribute  this  condition  to  chloro- 
form. 

Insanity  may,  in  very  rare  cases,  follow  chloro- 
formisation  of  predisposed  persons  (Savage).  (See 
Medico-Legal  Aspects  of  Anaesthesia,  Chap.  XII.). 

Effects  of  Eepeated  Inhalations. — Paul  Bert  made 
a  careful  study  of  the  effects  of  daily  administration  of 
chloroform  for  a  definite  time.  His  researches  were 
made  on  dogs.  After  gradual  failure  of  health,  these 
creatures  died  on  the  32nd  day  with  well  marked  wast- 
ing of  their  organs  and  muscles,  and  fatty  changes  in 
the  liver.  According  to  Kegnault  and  Dubois  (Dastre) 
workers  constantly  exposed  to  the  fumes  of  chloroform 
suffer  from  insomnia,  neuralgic  and  rheumatic  pains, 
with  marked  physical  and  mental  depression. 


AMYLENE.  131 


CHAPTEE   VI. 

Less  Commonly  Used  Anaesthetics. 
Amylene — Ethjldene  Dichloeide — Beomide    of  Ethyl. 

Amylene. 

Amylene  (C5H10),  a  translucent,  colourless,  thin,  mo- 
bile liquid,  possessed  of  an  odour  which  is  midway 
between  chloroform  and  ether  in  pungency,  was  dis- 
covered by  Balard  in  1844.  It  has  a  sp.  gr.  of  *6549> 
boils  about  102°  F.  (38-8  G.)  (Watts),  although  the  boil- 
ing point  varies  somewhat :  it  burns  with  a  luminous 
white  flame.  Hardly  soluble  in  water,  it  is  freely  so  in 
alcohol  and  ether.  When  mixed  with  air  it  explodes 
on  heating,  and  therefore  should  not  be  used  in  near 
proximity  to  flame. 

Preparation. — Zinc  chloride  in  concentrated  solu- 
tion is  heated  with  amylic  alcohol  to  266°  F.,  distilled 
from  a  water-bath  over  caustic  potash  and  afterwards 
rectified. 

Physiological  action. — Snow  made  some  experi- 
ments with  this  substance,  and  found  small  animals 
required  a  10  per  cent,  vapour  before  losing  conscious- 
ness, that  20  per  cent,  produced  deep  insensibility,  while 
25  per  cent,  could  be  respired  with  perfect  safety.  With 
10  per  cent,  the  "  second  stage  "  of  anaesthesia  is  pro- 
duced, i.e.,  the  mental  faculties  without  being  sus- 
pended are  impaired ;   occasionally  patients  remember 

k  2 


132  ANAESTHETICS. 

what  occurs  during  this  period,  and  partial  anaesthesia 
exists.  Snow  stated  that  "  over -narcotism  of  the  heart 
with  paralysis  of  its  muscle  "  could  he  attained  with 
amylene,  hut  that  sudden  death  from  this  cause  was 
less  liahle  to  occur  than  with  chloroform.  He  found 
also  that  40  per  cent,  of  amylene  would  he  required  to 
effect  such  a  mode  of  death. 

In  1856,  Snow  employed  amylene  to  produce  general 
anaesthesia.  He  found  it  occasioned  little  or  no  sick- 
ness. The  anaesthesia  appeared  with  great  rapidity, 
sometimes  hefore  consciousness  was  lost ;  the  recovery 
was  speedy  and  usually  unaccompanied  by  headache, 
giddiness,  or  other  unpleasant  symptoms.  Dr.  Snow 
did  not  push  the  narcotism  far  enough  to  induce  coma ; 
in  most  of  his  patients  the  ciliary  reflex  persisted  (thus 
contrasting  with  the  effects  of  chloroform).  The  in- 
duction of  narcosis  by  this  agent  is  tranquil.  Save  in 
exceptional  cases  amylene  produces  complete  muscular 
relaxation.  The  pulse  is  increased  in  frequency,  espe- 
cially during  the  earlier  stage  of  amylene  narcosis.  Re- 
spiration is  quickened  as  under  ether.  The  pupils  re- 
main of  natural  size,  unless  the  anaesthetic  he  pushed, 
when  they  dilate.  The  face  flushes  and  sometimes 
perspiration  bursts  out,  hut  the  salivary  and  bronchial 
secretions  are  not  augmented.  A  tendency  to  hilarity 
evinces  itself  in  some  persons  just  as  they  are  passing 
into  the  second  stage.  Mental  excitement  is  usually 
absent.  Rigidity  and  struggling  seldom  occur  under 
amylene,  a  fact  which  Snow  believed  was  due  to  the 
slighter  degree  of  narcosis  needed  to  induce  anaesthesia 
when  that  substance  was  employed.  The  great  volatility 
(great  as  ether),  and  the  slight  solubility  of  amylene, 
make  its  liberation  from  the  blood  very  rapid ;  hence 


AMYLENE.  133 

recovery  from  the  effects  of  the  drug  takes  place  with 
great  celerity.  In  some  persons  laughter  and  singing 
are  provoked,  but  these  phenomena  usually  pass  off  if 
the  amylene  be  withheld  for  one  or  two  inspirations. 
The  Glasgow  Commission  failed  to  obtain  satisfactory 
anaesthesia  with  amylene.  More  recently  this  substance 
has  been  used  in  Germany  under  the  name  of  Pental 
with,  it  would  seem,  encouraging  results. 

Mode  of  administration, —The  vapour  of  amy- 
lene must  be  of  such  a  strength  as  to  induce  anaesthesia 
in  three  minutes  ;  if  a  weaker  vapour  be  used,  no 
matter  how  long  it  is  persevered  with,  it  will  fail  to 
produce  an  effect.  Snow  employed  the  same  inhaler 
as  for  chloroform  (see  p.  111).  The  patient  once  well 
under,  Snow  re- applied  the  inhaler  every  half  minute, 
otherwise  he  found  consciousness  returned.  Amylene 
may  be  given  in  a  cone,  or  by  the  open  method ;  the 
last,  however,  is  not  well  adapted  for  its  exhibition,  on 
account  of  its  extreme  volatility. 

Snow,  suggested  the  dosimetric  system  for  amylene. 

After-effects  and  dangers. — Snow  found  the 
after-effects  were  fewer  and  less  severe  than  those  subse- 
quent to  chloroform  or  ether.  Sickness  occurred  twice 
only  out  of  238  cases  ;  headache  was  slight  and  transi- 
ent ;  hysterical  symptoms  were  shown  by  a  few  women. 

Two  deaths  occurred  in  Snow's  practice,  the  144th 
and  the  238th  cases,  and  were  attributed  b}r  him  to  the 
patients  inhaling  too  strong  a  vapour  (30  per  cent.)  of 
amylene.  In  Snow's  opinion  the  variation  of  the  boil 
ing  point  in  different  specimens  fully  accounts  for  these 
unhappy  fatalities.  Thudichum  asserts  that  the  sam- 
ples employed  by  Snow  in  these  cases  really  contained 
no  amylene,  but  only  intermediate  hydrocarbons. 


13-4  ANESTHETICS. 

Treatment. — The  steps  requisite  to  avert  such 
accidents  are  similar  to  those  described  under  "  Acci- 
dents during  the  administration  of  chloroform." 


it> 


Ethidene    Chloride. 

Ethidene  Chloride  (ethidene  dichloride),  more  pro- 
perly ethilidene  chloride,  C2H4C12,  has  a  sp.  gr.  1-189, 
and  boils  at  about  136-4°  F.  (58°  C),  (sp.  gr.  1-182 
and  B.P.  59°  C.  Dastre) ;  this  boiling  point  is  not, 
however,  uniform.  It  was  first  prepared  by  Kegnault 
by  the  action  of  chlorine  upon  chloride  of  ethyl.  Clover 
used  samples  with  a  sp.  gr.  of  1-225  and  B.P.  239°  F. 
(115°  C).  According  to  Watts,  it  is  identical  with 
monochlorinated  chloride  of  ethyl,  C2H4C1.C1,  which 
possesses  a  boiling  point  of  04°  C.  and  a  sp.  gr.  1-174 
at  17°  C.  It  is  a  colourless  transparent  oily  fluid, 
tasting  and  smelling  like  chloroform.  It  is  prepared 
from  aldehyde  by  acting  upon  it  with  pentachloride  of 
phosphorus.  It  is  also  formed  as  a  bye-product  in  the 
preparation  of  chloral,  and  separated  by  distillation 
and  subsequent  fractionation.  Insoluble  in  water,  it  is 
freely  taken  up  by  alcohol,  chloroform,  ether,  and  oils. 
It  is  less  inflammable  than  chloroform.  It  is  difficult 
to  preserve,  as  in  contact  with  air  it  rapidly  decomposes 
and  becomes  acid  in  reaction  and  useless  for  anesthetic 
purposes. 

Dr.  Snow  was  the  first  to  employ  this  anaesthetic  in 
England  (June  20th,  1851),  and  it  was  subsequently 
used  extensively  by  Clover,  who  I  believe,  until  the 
time  of  his  death,  entertained  a  very  high  opinion  of  it. 
In  Germany,  Liebreich,  Langenbeck,  Sauer,  and  Steflen, 
have  used  it  and  published  records  of  cases. 


ETHIDENE    CHLORIDE.  135 

Physiological  action. — The  Committee  of  the 
British  Medical  Association  carefully  worked  out  this 
subject. 

Frogs  compelled  to  inhale  the  vapour  become  rapidly- 
narcotised  (4  minutes).  Their  hearts,  however,  beat  on 
unaffected  for  twenty- six  minutes. 

Warm-blooded  animals  speedily  passed  under  the  in- 
fluence of  this  ether  (4  minutes),  and  remained  nar- 
cotised without  the  failure  of  the  heart.  Being  exposed 
and  watched  while  artificial  respiration  was  maintained, 
the  heart  showed  some  slowing,  but  without  any  mate- 
rial weakening.  In  an  experiment  made  to  compare 
ethidene  with  chloroform,  a  dog  was  narcotised  with 
ethidene  and  the  cardiac  movements  studied.  While 
under  this  agent  no  interference  with  the  rhythm  was 
observed ;  when,  however,  chloroform  was  substituted, 
the  right  heart  grew  distended  and  dark,  and  rapid 
depreciation  of  cardiac  force  occurred.  The  Committee 
concluded  "practically  a  dog  will  live  for  a  lengthened 
period  in  a  state  of  complete  anaesthesia  under  the  in- 
fluence of  ethidene  dichloride,  whilst  it  will  die  in  a 
short  time  when  chloroform  is  used." 

Blood-pressure  is  slightly  lowered  by  ethidene,  the 
lowering  taking  place  quite  gradually,  but  after  a  while 
a  partial  recovery  occurs,  which  is  assumed  to  be  due 
to  the  heart  accommodating  itself  to  the  influence  of 
the  narcotic. 

Respiration  is  slowed  and  may  become  spasmodic 
and  jerky,  persisting  even  when  the  heart  has  percep- 
tibly ceased  to  beat. 

Upon  human  beings,  ethidene  exercises  the  following 
effects  : — At  first  a  pleasurable  glow  extends  over  the 
whole  body,  then  within  a  minute  or  two  the  senses  are 


13G  ANESTHETICS. 

confused,  and  often  singing  or  whistling  is  induced. 
Some  muscular  rigidity  then  appears  and  anaesthesia 
follows.  Patients  take  a  longer  time  to  recover  con- 
sciousness than  when  chloroform  is  used,  but  they  ex- 
perience fewer  after-effects.  Thus,  as  soon  as  they 
come  to,  they  can  stand  or  walk  (Clover)  and  are  able 
to  express  themselves  with  clearness.  No  headache 
actually  follows,  vomiting  is  present  after  about  one- 
third  of  the  cases  of  major,  and  one-twentieth  of  minor, 
operations.  This  vomiting  is  less  severe  than  that 
which  follows  chloroform  and  does  not  persist  so  long. 

There  is  sometimes  a  little  convulsive  twitching. 
As  the  patient  passes  into  unconsciousness,  his  breath- 
ing grows  stertorous  and  his  pupils  dilate,  but  if  air  be 
now  admitted,  the  stertor  will  pass  off  and  the  pupils 
resume  their  normal  size.  The  pulse  is  liable  to  flag 
under  ethidene,  and  hence  caution  is  needed  in  its  em- 
ployment. In  the  fatal  cases  recorded,  the  patient  died 
from  heart  failure,  the  myocardium  being  pathologically 
fatty. 

Methods  of  administration. — Mr.  Clover,  who 
gave  ethidene  1877  times  with  but  one  death,  recom- 
mended administrators  to  commence  the  inhalation 
with  nitrous  oxide,  and  then  to  prolong  anaesthesia  by 
ethidene  contained  in  his  ether  inhaler.  Of  course  the 
initiation  with  gas  is  matter  of  choice.  When  given 
from  an  ether  inhaler  (see  article,  Ether)  the  anaesthetic 
should  be  pushed  until  after  the  stage  of  struggling  has 
passed ;  subsequently  it  should  be  given  far  more  spar- 
ingly, the  inhaler  being  lifted  from  the  face  every  third 
or  fourth  inspiration  for  the  admission  of  fresh  air. 
The  patient  becomes  anaesthetised  in  three  to  five  min- 
utes.    Dilatation  of  the  pupil  and  stertor  are  signs 


HYDROBROMIC    ETHER.  137 

indicative  of  the  necessity  of  reducing  the  amount  of 
anaesthetic  given.  The  Glasgow  Committee  gave  ethi- 
dene  hy  the  open  method  upon  a  towel. 

Ethidene  is  also  given  through  Junker's  inhaler,  or 
Snow's  chloroform  inhaler  may  be  substituted. 

Accidents  and  after-effects.—  These  are  similar 
in  kind  to  those  treated  under  the  article  Chloroform, 
to  which  the  reader  is  referred,  (see  also  Accidents  of 
Anaesthesia,  Chap.  X.). 

At  least  two  deaths  have  occurred  during  the  use  of 
this  anaesthetic. 


Hydrobromic  Ether. 

Hydrobromic  ether  (bromide  of  ethyl)  C2H5Br,  sp.  gr. 
1-4783,  boils  at  104°  F.  (40-7°  C).  It  is  a  colourless 
translucent  liquid,  with  a  neutral  reaction,  ethereal 
smell,  and  a  pungent  sweet  taste  with  a  somewhat 
burning  after-flavour.  It  is  ignited  with  difficulty,  and 
burns  with  a  green,  smokeless  flame  emitting  an  odour 
of  hydrobromic  acid  (Lowig).  It  is  prepared  by  dis- 
tilling alcohol  (ethylic)  with  either  bromine,  hydro- 
bromic acid  or  bromide  of  phosphorus.  It  is  only 
slightly  soluble  in  water,  but  freely  so  in  ether  or 
alcohol.  Serullas  discovered  this  substance  in  1827, 
but  to  Nunneley,  of  Leeds,  we  are  indebted  for  its  re- 
cognition as  an  anaesthetic  (1849). 

It  was  again  brought  into  notice  in  1865  by  Nunneley, 
but  eventually  he  gave  up  its  use  mainly  owing  to  the 
extreme  difficulty  of  obtaining  it  pure  and  on  account  of 
its  great  cost.  Dr.  Squire  gave  the  results  of  his  ex- 
perience of  its  use  in  1881,  and  Dr.  B.  "W.  Bichardson,  a 


138  ANAESTHETICS. 

staunch  supporter  of  this  agent,  wrote  (Asclepiad,  1885) 
favourably  of  its  claims,  and  urged  that  pure  samples 
were  free  from  the  dangers  which  arise  with  the  com- 
mercial bromide. 

Physiological  action. — Eabuteau  has  made  care- 
ful researches  upon  the  subject.  Seeds  not  germinating 
are  unaffected  by  it  but  do  not  germinate  ;  plants  die 
when  placed  in  its  atmosphere  after  a  very  short  ex- 
posure. Frogs  become  deeply  anaesthetised  when  im- 
mersed in  watery  solutions.  Upon  human  beings 
it  produces  unconsciousness  and  anaesthesia  in  one 
minute,  and  complete  muscular  relaxation  in  two  or 
three  minutes.  No  suffocation  or  laryngeal  irritation 
appears  to  exist,  although  there  is  much  congestion  of 
the  head  and  neck,  and  an  increased  secretion  of 
mucus  which  may  give  trouble.  The  breathing  is 
quickened,  the  pulse  accelerated,  and  the  heart's  action 
somewhat  weakened.  The  pupils  dilate.  Keturn  to 
consciousness  after  withdrawal  of  the  ether  is  very 
prompt.  Vomiting  is  said  to  occur  frequently  during 
the  administration,  and  even  to  continue  for  some  hours 
succeeding. 

Blood-pressure,  according  to  Wood,  is  slightly  re- 
duced by  small,  and  very  considerably  by  large,  quanti- 
ties. Where  death  ensues  it  is  due  to  cardiac  failure 
(Wolff  and  Lee)  ;  but  these  statements  are  denied  by 
some  observers.  Ott  believes  ethyl  bromide  kills  by 
direct  action  upon  the  respiratory  centre,  and  does  so 
whether  injected  subcutaneously  or  inhaled.  The  heart 
failure,  he  thinks,  is  secondary  to  the  respiratory  trouble. 

Method  of  administration. — Ethyl  bromide 
must  be  given  like  ethyl  oxide  (Sulphuric  Ether), 
air  being  excluded.     Turnbull,  who  has  made  careful 


CASES    FOR    ETHYL    BROMIDE.  139 

study  of  this  substance,  insists  upon  tli3  necessity 
of  quickly  getting  the  patient  under  the  influence 
of  the  vapour.  An  Allis's  inhaler  answers  very  -well, 
or  an  Ormsby's  apparatus.  The  inhalation  must  be 
stopped  when  palatine  stertor  or  loss  of  conjunctival 
reflex  occurs  (Silk).  There  is  said  to  be  less  struggling 
than  with  ether,  but  violent  struggling  certainly  does 
in  some  instances  take  place.  Owing  to  the  great 
rapidity  with  which  consciousness  returns,  extreme 
attention  is  needed  on  the  part  of  an  anaesthetist  to 
maintain  narcosis.  The  respiration  and  pulse  require 
watching  throughout  the  administration.  No  prolonged 
operation  must  be  attempted  under  ethyl  bromide, 
forty  minutes  being  the  limit  of  time  during  which  it 
may  be  safely  administered. 

Cases  suitable  for  Ethyl  Bromide. 

Short  operations  and  those  of  minor  sur- 
gery.— In  dental  operations  the  rapidity  with  which 
the  patient  shakes  of!  narcosis  renders  ethyl  bromide  of 
little  more  value  than  nitrous  oxide,  while  it  would  not 
seem  to  equal  it  in  safety.  The  use  of  this  substance 
in  dental  practice  has  recently  been  strongly  advocated 
in  Germany,  and  Dr.  Silk  using  it  in  the  Dental  Depart- 
ment of  Guy's  Hospital  speaks  favourably  of  it.  The 
frequency  of  more  or  less  unpleasant  after-effects  which 
he  states  occurred  among  his  patients  would  seem  to 
detract  from  its  value  in  this  branch  of  surgery.  In 
obstetric  practice  it  is  said  by  Dr  Laurence  Turnbull  to 
be  of  the  utmost  utility,  since  it  rapidly  induces  uncon- 
sciousness and  the  patient  as  speedily  regains  her 
senses.      It  must  not  be  forgotten,  however,  that  when 


140  ANAESTHETICS. 

bromide  of  ethyl  is  given  iu  small  doses,  much  mus- 
cular spasm  results,  which  is  not  desirable  in  Reconcile- 
ments. 

Dangers  resulting  from  the  use  of  Hydro- 
bromic  Ether. — Richardson,  entertaining  a  very 
high  opinion  of  ethyl  bromide  as  an  anaesthetic,  denies 
that  fatalities  have  followed  its  employment.  Eight 
deaths  are  stated  to  have  resulted  from  its  administra- 
tion, but  some  of  these  were  in  reality  due  to  impurities 
contained  in  the  sample  used.  Dastre  points  out  that 
pure  hydrobromic  ether  has  a  sweet  ethereal  smell,  but 
when  impure  the  odour  is  most  unpleasant.  According 
to  Dr.  Laurence  Turnbull,  most  of  the  ethyl  bromide 
sold  is  impure,  containing  free  bromine,  carbon  bromide 
(CoBrJ,  phosphorus,  and  bromoform.  Further,  this 
substance  is  very  unstable  and  readily  decomposes, 
liberating  free  bromine.  The  presence  of  these  bodies 
renders  the  impure  ethyl  bromide  singularly  dangerous, 
and  until  we  can  be  sure  of  the  purity  of  any  given 
sample  I  think  we  are  scarcely  justified  in  its  use  for 
anaesthetic  purposes. 

Complications. 

Muscular  spasm  may  be  so  pronounced  as  to 
interfere  with  respiration. 

Excitement  instead  of  insensibility  may  appear. 

Persistent  vomiting  has  been  recorded  as  follow- 
ing its  employment.  Persistent  nausea  also  occurs 
even  when  vomiting  does  not  occur. 

Heart  failure  may  occur.  Various  degrees  of 
faintnees  and  collapse  not  infrequently  follow  its  use 
(Silk). 


COMPLICATIONS.  141 

In  no  case  is  it  safe  to  continue  the  administration 
of  this  anaesthetic  for  more  than  forty  minutes.  (Dr. 
Laurence  Turnbull). 

Treatment. — The  directions  given  elsewhere  (Chap. 
X.)  apply  to  the  recovery  of  the  apparently  dead  from 
ethyl  bromide.  Thus,  artificial  respiration  must  be  re- 
sorted to  at  once,  and  the  mouth  and  pharynx  cleared 
of  secretion  without  delay. 

Amyl  nitrite  may  be  tried. 


142  ANAESTHETICS, 


CHAPTER   VII. 

Anesthetic  Mixtures. 

These  are  of  two  classes  : — 1.  Admixtures  of  members 
of  the  alcohol  or  ethereal  series.  2.  Alcoholic  or 
ethereal  anaesthetics  with  alkaloids  or  other  bodies. 

The  following  are  the  best  known  and  most  useful 
members  of  the  first  class  : — 

The  A.  C.  E.  Mixture. — Compound  of  1  part  alcohol, 
sp.  gr.  -888,  2  parts  chloroform,  sp.  gr.  1*497,  and  3 
parts  ether,  sp.  gr.  *735. 

The  Vienna  Mixture. — 1  part  of  chloroform  to  3  of 
ether. 

The  Mixture  recommended  by  Linhart  :  1  part  alco- 
hol, 4  chloroform. 

Methylene. — Methylic  alcohol  30  per  cent,  and  70 
per  cent,  chloroform  (Regnauld  and  Villejean). 

Billroth's  Mixture. — 3  parts  chloroform,  1  each  of 
alcohol  and  ether. 

The  A.  C.  E.  mixture,  which  was  originally  pro- 
posed by  Dr.  George  Harley,  is  strongly  recommended 
by  the  Anaesthetic  Committee  of  the  Royal  Medico- 
Chirurgical  Society  of  London.  They  speak  of  its 
action  as  midway  between  that  of  chloroform  and  ether. 
It  has  been  largely  used  in  England,  and  although  not 
without  objections,  is  a  good  substitute  in  many  cases 
when  ether  cannot  be  taken.  The  main  drawback  to 
the  employment  of  this  and  all  other  mixtures  is  that 
the  substances   employed   in   their  formation   do   not 


ANAESTHETIC    MIXTURES.  143 

evaporate  in  the  ratio  in  which  the  fluids  are  mixed, 
and  hence  it  is  impossible  to  be  quite  sure  what  per- 
centage vapour  of  chloroform  is  being  inhaled.  To 
obviate  this  difficulty,  Ellis  proposed  to  blend  the 
vapours  of  alcohol,  chloroform  and  ether,  in  a  specially 
constructed  apparatus,  and  so  administer  a  true  vapour 
mixture  to  the  patient.  The  arrangement  he  used  is 
too  complicated  for  practical  purposes,  and  his  method 
has  never  been  received  with  much  favour.  In  three 
chambers,  known  weights  of  the  anesthetics  were 
evaporated  ;  these  chambers  could  at  will  be  made  to 
communicate  with  a  common  chamber,  and  from  this 
the  patient  was  anaesthetised. 

Mr.  Martindale  has  proposed  an  admirable  volumetric 
mixture,  the  ingredients  of  which  evaporate  almost  uni- 
formly. It  consists  of  absolute  alcohol,  sp.  gr.  '795,  1 
volume,  chloroform,  sp.  gr.  1*498,  2  volumes,  pure 
ether,  sp.  gr.  *720,  3  volumes. 

Method  of  employment. — This  may  be  given  in 
a  Clover's  ether-inhaler,  a  cone,  or  even  by  the  open 
method.  I  find  Allis'  inhaler  also  answers  well,  and 
recently  have  employed  Krohne's  cone  fitted  with  the 
feather  respiration  register  (p.  116)  and  have  found  it 
very  successful  and  pleasant  to  manipulate.  Junker's 
inhaler,  fitted  with  the  flannel  mask,  is  very  convenient 
for  giving  the  A.  C.  E.  mixture,  especially  to  children. 
With  the  open  method,  much  ether  vapour  escapes 
into  the  surrounding  air,  causing  inconvenience  and 
delay  in  the  onset  of  insensibility,  and  further  rendering 
the  mixture  relatively  rich  in  chloroform  while  deficient 
in  ether.  No  special  directions  are  needed  if  the 
chapters  upon  chloroform  and  ether  administration 
have  been  read.     The  fact  that  chloroform  is  present 


144  ANESTHETICS. 

in  the  mixture  makes  it  obligatory  that  plenty  of  air  be 
allowed  the  patient,  to  effect  which  the  cone  or  inhaler 
should  frequently  be  raised  from  his  face.  Both  re- 
spiration and  pulse  must  be  carefully  noted,  as  fainting 
and  asphyxial  troubles  may  occur  during  the  employ- 
ment of  the  A.  C.  E.  mixture. 

After-effects  are  much  the  same  as  those  of  chloro- 
form or  ether.  Deaths  have  occurred  during  the  use  of 
the  A.  C.  E.  mixture. 

Richardson's  mixture  consists  of  2  parts  alcohol, 
2  parts  chloroform  and  3  of  ether.  Dr.  Kichardson 
states  that  this  mixture  works  very  well,  and  that  he 
has  never  lost  a  case  during  its  employment. 

The  Vienna  mixture  (1  part  chloroform,  3  of 
ether),  stated  to  have  been  employed  eight  thousand 
times  without  a  casualty,  may  be  given  practically  in 
the  same  way  as  ether,  save  that  care  must  be  taken 
that  the  patient  shall  respire  fresh  air  at  frequent  in- 
tervals. 

Linhart's  mixture  is  administered  similarly  to 
chloroform ;  the  same  care  and  watchfulness  being 
necessary,  as  most  of  the  risks  of  chloroform  are  pre- 
sent with  its  use. 

Methylene  or  "bichloride  of  methylene" — so 
called,  but  which  is  stated  by  Eegnauld  and  Villejean 
to  be  merely  a  mixture  of  methylic  alcohol  and  chloro- 
form similar  to  Linhart's  mixture  above  given.  It 
consists  of  methylic  alcohol  30  per  cent,  and  chloroform 
70  per  cent. 

The  so-called  "liquid  of  Eegnauld"  consisted  of 
80  per  cent,  chloroform,  20  per  cent,  methylic  alcohol. 
The  Glasgow  Committee  found  methylene  possessed  no 
definite    and    constant    boiling   point,    a   fact   further 


ANESTHETIC    MIXTURES. 


115 


corroborating  the  assertion  of  the  French  chemists. 
It  was  also  pointed  out  by  this  committee  that  the 
physiological  behaviour  of  this  body  was  identical  with 
that  of  chloroform.  I  have  found,  experimenting  upon 
the  frog's  heart,  that  methylene  and  chloroform  affect 
the  heart  in  precisely  the  same  way  and  give  identical 
cardiograms.  But,  in  explaining  the  diverse  results  at 
which  various  observers  have  arrived,  we  must  remem- 
ber that  although  the  boiling  points  of  methylic  alcohol 
and  chloroform  are  not  very  wide  apart,  yet  the  con- 
stituents of  this  mixture  evaporate  at  varying  tempera- 
tures, so  that  at  the  end  of  the  dose  pure  chloroform  is 
given  up,  while  at  the  beginning  only  a  small  percent- 
age of  it  is  present  in  the  evaporating  alcohol.  It  is 
more  agreeable  than  ether,  possessing  the  fragrant 
smell  of  chloroform.  Its  safety  is  probably  only  that 
of  diluted  chloroform,  and  many  deaths  have  followed 
its  use. 

Dr.  Eichardson,  the  first  who  introduced  methylene 
into  English  practice,  writing  in  the  Asclepiad  (1884), 
adhered  to  his  original  statements  in  favour  of  methy- 
lene. He  holds  that  although  many  samples  are  mere 
mixtures,  yet  pure  bichloride  of  methylene  is  anaesthe- 
tic. This  is  absolutely  denied  by  the  French  chemists 
cited  above,  who  state  that  the  pure  substance  (bi- 
chloride of  methylene)  is  not  an  anaesthetic,  but  a 
powerful  convulsant,  and  proves  fatal  to  animals  in  a 
few  seconds. 

Methods  of  employment. — Although  methylene 
may  be  given  by  the  open  method,  it  is  more  commonly 
administered  from  a  Junker's  inhaler  (see  description 
page  113).  Methylene  acts  precisely  like  chloroform, 
and  its  use  is  fraught  with  dangers  which  differ  not  in 


146  ANESTHETICS. 

kind,  but  in  degree,  from  those  present  when  chloro- 
form is  used. 

Both  the  respiration  and  pulse  must  be  sedulously 
watched,  and  the  utmost  vigilance  displayed  to  avoid 
accumulation  of  vapour  in  the  lungs.  With  the  use 
of  an  inhaler,  it  is  most  important  to  avoid  pushing  the 
narcosis  too  far.  When  a  patient  has  once  become  un- 
conscious, the  amount  of  air  blown  over  (Junker's  appa- 
ratus) should  be  much  lessened,  thus  he  can  easily  be 
kept  anesthetic  with  a  very  small  percentage  of  methy- 
lene vapour.  It  must,  however,  be  borne  in  mind  that 
methylene  being  diluted  chloroform,  the  subject  is  apt 
to  regain  consciousness  somewhat  more  rapidly  than 
during  the  use  of  simple  chloroform. 

The  after-effects  of  methylene  are  those  following  the 
use  of  chloroform,  they  are,  however,  often  less  severe. 

Billroth' s  mixture  (chloroform  3  parts,  alcohol 
and  ether  each  1  part),  is  but  little  known  or  employed 
in  England.  It  contains  a  high  percentage  of  chloro- 
form, and  hence  needs  careful  handling.  It  should  be 
administered  either  by  the  open  method,  or  if  an 
inhaler  be  used,  Junker's  or  the  simple  fianuel  cap 
will  answer.  In  either  case  the  patient  must  be 
allowed  plenty  of  fresh  ah*. 

Similar  dangers  are  imminent,  and  precautions 
needed,  as  in  the  administration  of  chloroform. 
Deaths  have  occurred  during  the  use  of  Billroth 's 
mixture. 


CHLOROFORM    AND    MORPHINE.  147 


Mixture  of  Chloroform  or  Ether   with   Alkaloids, 

ETC. 

Chloroform  and  morphine  (Nussbaum). — Nuss- 
batim,  of  Munich,  was  the  first  to  employ  this  mixture 
method  in  Germany  (1873),  although  Claude  Bernard 
had  studied  the  method  experimentally  some  years 
(1869)  previously,  having  had  occasion  to  give  mor- 
phine to  a  dog  recovering  from  chloroform.  Injections 
of  morphine,  gr.  -§-  to  -|,  or  in  some  cases  more,  hypo- 
dermically,  half  an  hour  before  giving  an  inhalation  of 
chloroform,  are  stated  to  possess  the  following  advan- 
tages : — Less  chloroform  is  needed,  while  the  stupor  is 
more  prolonged.  If  the  morphine  be  given  immediately 
before,  it  in  some  cases  prolongs  the  period  of  excitement. 
Drunkards,  and  persons  who  show  little  amenity  to 
chloroform,  soon  pass  under  its  influence  after  a  dose 
of  morphine.  The  patient  is  usually  more  completely 
relaxed  and  passive,  the  breathing  is  quieter,  and  it 
is  stated  (Kappeler)  that  the  depressant  action  upon 
the  heart  is  diminished. 

The  stage  of  excitement  is  shortened,  and  cerebral 
circulation  while  under  morphine  is  markedly  lessened, 
so  that  for  operations  involving  the  opening  of  the 
meninges  and  the  cutting  of  the  brain  substance,  this 
combination  is  most  valuable. 

Excitable  persons  about  to  be  anaesthetised  will  often 
be  calmed  by  morphine. 

Upon  the  other  hand,  vomiting  is  more  frequent 
when  morphine  is  used.  Poncet,  from  a  wide  experi- 
ence during  the  Franco-Prussian  war,  abandoned  the 
method,  owing  to  the  frequency  with  which  prolonged 

l  2 


148  ANESTHETICS. 

stupor,  and  dangerous  depression  of  the  temperature 
occurred  after  its  use. 

Morphine  in  some  produces  great  excitement,  and 
this  by  the  addition  of  chloroform  may  be  magnified  to 
a  very  inconvenient  extent. 

"When  this  combination  is  employed,  it  is  important  to 
restrict  the  amount  of  chloroform  given  ;  indeed  when 
the  patient  is  once  fairly  narcotised,  very  little  more 
chloroform  will  be  needed  unless  the  operation  be  a 
very  prolonged  one.  Care  must  be  exercised  that  only 
a  weak  vapour  is  used,  since  the  patient  wm  take  but 
little  notice  of  its  pungency,  and  so  one  of  the  usual 
safeguards  is  lost.  Caution  must  also  be  displayed  in 
employing  this  mixture  when  severe  haemorrhage  is 
likely  to  take  place  into  the  pharynx,  as  the  patient  is 
not  easily  roused,  and  the  danger  of  blood  entering  the 
lungs  is  increased. 

According  to  Eegnier  there  is  a  grave  danger,  due  to 
the  morphine  lessening  the  elimination  of  the  chloro- 
form and  so  leading  to  over-dosage.  He  lost  one 
patient  when  this  method  was  used,  and  regards  it  as 
rather  increasing  the  patient's  chance  of  mishap  from 
the  chloroform.  Dastre  points  out  also  the  liability 
there  is  to  respiratory  failure  under  its  use. 

Demarquay  has  very  justly  indicated  that  the  chief 
dangers  of  this  method  of  mixed  anaesthesia  lie  in 
want  of  caution  in  not  limiting  the  dose  ;  large  injec- 
tions of  morphine  preceding  chloroform  administration 
certainly  have  a  danger  of  producing  asphyxia  through 
paralysis  of  the  respiratory  centre. 

Morphine,  atropine  and  chloroform  (Dastre  and 
Morat). — It  was  pointed  out  some  years  ago  that  atro- 
pine in  paralysing  the  vagus  might  be  a  valuable  anti- 


MORPHINE    AND    ETHER.  149 

dote  to  chloroform,  by  preventing  reflex  inhibition  of 
the  heart  through  the  par  vagum.  I  have  found  the 
addition  of  gr.  Ti^  of  atropine  to  gr.  J  of  morphine  to 
be  an  advantage,  when  that  last  alkaloid  is  employed 
synergetically  with  chloroform. 

This  plan  which  goes  by  the  name  of  the  Dastre 
Morat  method  in  France  is  said  by  its  inventors  to  be 
safer  than  Nussbaum's  method.  Aubert,  of  Lyons, 
employed  it  in  practice  and  speaks  well  of  it.  The 
injection  is  made  15  or  30  minutes  before  the  com- 
mencement of  the  operation.  The  mixture  Dastre 
recommends  is  Morph.  Hydrochlor.  10  centigrm., 
Atropin.  Sulph.  5  milligrm.,  Aq.  destilh  10  grammes, 
one  cubic  centimetre  or  1*5  c.c.  being  injected.  The 
use  of  atropine  in  this  way  is  said  to  lessen  the  after- 
sickness,  and  to  abrogate  salivation  and  bronchial 
secretion. 

Morphine  and  ether. — It  has  been  proposed  to 
exhibit  morphine  before  ether,  similarly  as  before 
chloroform,  but  the  method  possesses  disadvantages 
in  its  liability  to  induce  prolongation  of  the  stage  of 
excitement.  It  may  induce  very  violent  struggling  and 
increase  the  after-headache,  prostration,  and  vomiting. 
Kappeler,  who  has  experimented  with  this  mixed 
method,  states  that  he  has  completely  failed  in  several 
cases  in  which  he  attempted  to  narcotize  patients  with 
ether  subsequently  to  hypodermic  injections  of  morphine. 

It  is  not,  however,  clear  whether  Kappeler's  results 
should  be  considered  quite  so  absolute  as  his  state- 
ments would  lead  one  to  suppose.  Certainly  in  cases 
at  University  College  Hospital  in  which  the  method 
was  employed,  no  great  struggling  or  inconvenience 
was  observed. 


150  ANAESTHETICS. 

Chloroform  and  amyl  nitrite  ("  Chloramyl," 
Sanford). — x\inerican  physiciaus  have  employed  this 
mixture  and  speak  well  of  it,  and  Dr.  Kichardson  in 
this  country  has  lent  it  his  support. 

It  is  claimed  that  chloroform,  when  mixed  with 
nitrite  of  amyl,  loses  many  of  its  dangers,  and  is  more 
ngreeable  to  take.  The  proportions  recommended  are 
3ij.,  to  the  pound  (Sanford),  and  nxxvi.  to  the  ounce 
(L.  B.  Balliet).  Dr.  Sanford  states  that  unless  a  very 
pure  sample  of  chloroform  is  obtained  the  mixture  is 
liable  to  become  milky  and  to  give  unsatisfactory  re- 
sults. He  also  suggests  that  when  the  administration 
of  the  mixture  is  likely  to  be  very  much  prolonged,  that 
it  is  well  to  use  less  nitrite  of  amyl  in  the  latter  stages 
of  the  operation. 

Upon  the  other  hand,  we  are  compelled  to  recognise 
that  such  a  mixture  possesses  several  undeniable  objec- 
tions. In  the  first  place  the  sp.  gr.  of  chloroform  is 
1*497,  that  of  nitrite  of  amyl,  -877,  so  no  permanent 
mixture  can  be  maintained,  a  drawback  which  even  a 
suggestion  to  "shake  the  bottle  well  before  use"  does 
not  abrogate.  Again,  nitrite  of  amyl  cannot,  as  is 
asserted,  be  considered  a  physiological  antagonist  of 
chloroform,  for  the  following  reasons  : — Nitrite  of  amyl 
lowers  blood  pressure  by  producing  paralysis  of  either 
the  muscular  coatings  of  the  vessels  or  of  the  vasomotor 
ganglia  controlling  them.  After  an  initial  fillip  to  the 
heart's  action  it  depresses,  and  may  if  pushed  even 
cause  syncope.  In  the  lower  animals  after  the  use  of 
nitrite  of  amyl,  the  heart  muscle  becomes  after  a  time 
paralysed.  Further,  the  respiratory  centre  is  depressed, 
while  the  motor  centres  in  the  spinal  cord  are  para- 
lysed.    It  would  thus  appear  that  so  far  from  nitrite 


CHLOROFORM  AND  CHLORAL.  151 

of  amyl  opposing  the  depressant  action  of  chloroform, 
it  probably  acts  similarly,  and  by  adding  it  to  that  nar- 
cotic we  are  still  more  prejudicing  the  patient's  chances 
of  recovery.  If  it  be  urged  that  successful  cases  of 
administration  stultify  any  such  theoretical  reasoning, 
the  answer  lies  in  a  consideration  that,  firstly,  the 
combination  was  probably  never  a  mixture  and  so  the 
patient  inhaled  chloroform  and  little  if  any  of  the  amyl 
nitrite  ;  and,  secondly,  that  just  as  we  find  very  many 
persons  whose  hearts  withstand  the  stress  of  chloroform 
depression,  so  many  would  survive  the  still  greater 
depression  of  chloroform  to  which  is  added  amyl  nitrite. 
I  cannot  find  records  of  any  instances  in  which  pro- 
longed anaesthesia  was  maintained  by  this  mixture. 
In  brief  operations  it  would  be  at  its  best ;  but  then  it 
is  in  lengthy  operations  that  the  depressant  action  of 
chloroform  is  to  be  most  feared. 

Method  of  employment. — The  method  of  em- 
ploying this  mixture  is  similar  to  that  of  chloroform. 

Chloroform  and  chloral. — The  preliminary  giv- 
ing of  chloral  was  first  suggested  by  Forne ;  it  is  said 
to  curtail  the  period  of  excitement  and  to  produce  an 
anaesthesia  comparable  to  that  which  ensues  when 
morphine  is  used  in  conjunction  with  chloroform. 

Dose. — Perrin  used  as  large  a  dose  of  chloral  as 
gr.  45  for  adults  (three  grammes)  before  chloroforming. 

An  alternative  plan  has  been  suggested,  viz.,  to  divide 
the  dose,  giving  half  by  the  mouth  and  half  by  the 
rectum.  Children  of  course  would  require  a  much 
smaller  dose. 

I  cannot  think  the  advantages  which  are  alleged  for 
this  method  in  any  way  counterbalance  the  dangers 
which  undoubtedly   attend  its  employment.      Chloral 


152  ANESTHETICS. 

acts  so  markedly  upon  the  heart  that  it  is  upon  that 
score  alone  a  deleterious  drug  to  be  used  with  chloro- 
form. 

Dastre  gives  as  much  as  two  to  five  grammes  of  chloral 
an  hour  before  administering  the  chloroform  by  inhala- 
tion. He  explains  the  action  of  the  agents  thus  : — the 
chloral  behaving  as  an  hypnotic  composes  the  patient 
to  sleep,  and  the  tranquility  and  lethargy  of  the  patient 
enable  the  administrator  to  maintain  true  anaesthesia 
by  the  use  of  a  small  quantity  of  chloroform. 

Other  combinations  of  chloroform,  e.g.,  that  of  Von 
Mering  (Chloeoform  one  volume,  Dimethylacetal  two 
volumes)  ;  that  of  Dr.  Wachsmuth  (Berlin),  who  adds 
one-fifth  part  of  oil  of  turpentine  to  his  chloroform, 
have  hardly  received  sufficient  trial  for  any  authorita- 
tive opinion  to  be  given  concerning  their  use.  Von 
Mering  claims  that  with  his  combination  there  is  no 
failure  of  respiration  or  heart,  and  no  lowering  of  blood 
pressure  ;  while  Dr.  Wachsmuth  states  that  the  addi- 
tion of  turpentine  to  chloroform  does  away  with  any 
fear  of  heart  failure. 

Chloral,  morphine  and  chloroform  (Trelat). — 
In  cases  in  which  it  is  desired  to  obtain  some  degree  of 
analgesia  without  absolute  loss  of  consciousness,  Pro- 
fessor Trelat  has  employed  a  mixture  of  four  to  nine 
grammes  of  hydrate  of  chloral,  twenty  to  forty  grammes 
of  syrup  of  morphine  in  120  grammes  of  water.  This 
is  divided  into  two  doses  which  are  swallowed  at  an  in- 
terval of  fifteen  minutes  (Dastre). 

"When  sufficiently  drowsy  the  patient  is  subjected  to 
operation.  In  cases  in  which  complete  anaesthesia  is 
required,  chloroform  is  inhaled  after  the  patient  has 
gone  to  sleep  from  the  dose.      The  method  may  be 


CHLOEAL  HYDEATE  AND  ETHEE.  153 

deserving  of  trial  in  some  exceptional  cases,  but  the 
same  objections  may  be  urged  against  it  as  apply  to  the 
method  of  Forne. 

Cocaine  and  chloroform  (Obalinski). — The  plan 
recommended  is  to  allow  the  patient  to  inhale  chloro- 
form in  the  ordinary  way  until  he  is  slightly  under  its 
influence,  and  then  to  inject  cocaine  hypodermically. 
The  dose  is  given  as  two  to  five  centigrammes  of  a  three 
per  cent,  solution.  It  is  claimed  that  a  very  small 
quantity  of  chloroform  suffices  to  effect  general  anaes- 
thesia, and  that  the  after-effects,  vomiting,  nervous  ex- 
citement, and  "  upset  "  are  less  liable  to  occur.  It  has 
also  been  asserted,  but  I  think  upon  insufficient  evi- 
dence, that  cocaine  and  chloroform  act  antagonistically 
upon  the  heart,  and  hence  there  is  less  fear  of  cardiac 
syncope  when  they  are  combined.  The  extreme  un- 
certainty of  cocaine  and  the  alarming  symptoms  to 
which  it  not  infrequently  gives  rise,  should,  I  think, 
make  one  very  cautious  in  the  employment  of  Obalin ski's 
method. 

Chloral  hydrate  and  ether. — Kappeler  used 
chloral  hydrate  in  forty  grain  doses  (children  half  this 
quantity)  as  a  preliminary  to  the  inhalation  of  ether. 
The  duration  of  anaesthesia  was  prolonged  and  the  re- 
covery retarded,  while  vomiting,  headache,  and  pro- 
stration, were  more  severe  than  when  ether  only  was 
employed. 

Priestley  Smith  (Heath's  Dictionary  of  Surgery,  Art, 
Cataract)  gives  fifteen  to  twenty  grains  of  chloral 
hydrate  twenty  minutes  before  administering  ether, 
and  finds  this  practice  answers  well  in  operations  for 
cataract. 

A  death  (Lyman)  has  followed  the  use  of  this  com- 
bination. 


15-4  ANESTHETICS. 

Nitrous  oxide  and  ether. — This  combination  is 
fully  described  under  "  Nitrous  Oxide,"  p.  41.  It  is 
the  best  method  of  producing  general  anaesthesia. 
When  complete  unconsciousness  has  been  attained  by 
giving  nitrous  oxide,  the  duration  may  be  prolonged 
by  allowing  the  gas  to  pass  through  the  ether ;  or  by 
turning  off  the  gas  altogether,  the  patient  may  be  kept 
anaesthetised  by  ether  for  a  lengthened  period. 

Clover's  Gas  and  Ether  Apparatus  enables  one  to 
regulate  the  supply  of  gas  or  ether  with  a  nicety  and 
precision  unattained  by  any  other  instrument.  The 
dangers  and  precautions  incident  to  this  method  are 
those  fully  described  in  the  chapters  upon  Nitrous 
Oxide  Gas  and  Ether. 


ANESTHETICS    IN    OBSTETRIC    PRACTICE.  155 


CHAPTEE   VIII. 
Anesthetics  in  Obstetric  Practice. 

^Vhether  or  not  an  anaesthetic  should  be  administered 
in  parturition  is  for  the  accoucheur  to  decide.  In 
eases  which  are  considered  suitable,  it  becomes  the 
anesthetist's  duty  to  render  his  aid. 

Choice  of  anaesthetics,  stage  -when  to  be 
administered,  etc. — As  a  rule  chloroform  is  pre- 
ferable to  ether,  unless  an  operation  is  to  be  performed, 
or  unless  the  patient  is  greatly  depressed  by  hsernor- 
rhage  or  shock.  The  A.  C.  E.  mixture  also  answers 
admirably  in  obstetric  practice.  Snow  advised  that 
chloroform  should  be  withheld  until  the  os  uteri  was  fully 
dilated  and  well  marked  expulsive  pains  had  appeared. 
He,  however,  made  an  exception  to  this  rule,  when 
during  an  earlier  stage  the  pains  were  very  severe. 

Spiegelberg,  in  summing  up  the  advantages  of  an 
anaesthetic  in  obstetric  surgery,  says  chloroform  not 
only  allays  the  pangs  of  childbirth,  but  checks  bearing- 
down  and  diminishes  the  tension  of  the  abdominal  and 
pelvic  muscles  as  well  as  that  of  the  uterus.  He  fur- 
ther extols  its  use  in  neuralgia  and  cramps  occurring 
during  parturition. 

In  normal  labour  little  chloroform  is  needed ;  if 
a  very  dilute  vapour  is  inhaled  the  patient  sinks  into 
a  quiet  sleep,  and  her  sensibility  to  pain  is  decreased. 
The  uterine  contractions  are  unaffected,  but  alihough 
during  the  pains  the  woman  may  groan  and  turn  over, 


156  AX-ESTHETICS. 

yet  her  complaints  are  but  slight,  and  as  soon  as  the 
pain  passes  off  sleep  again  comes  on. 

Rules  guiding  the  administration  :  — 

1.  Quietude  in  the  room  is  essential;  fresh  air  should 
from  time  to  time  be  admitted,  and  the  patient's 
posture  should  be  unconstrained. 

2.  Chloroform  should  be  commenced  when  the  labour 
is  in  its  second  stage  if  the  pains  are  very  severe, 
but  if  they  are  not  it  is  best  to  wait  until  the 
foetal  head  is  on  the  perineum.  As  a  rule  the 
chloroform  should  not  be  given  during  the  in- 
tervals between  the  pains,  unless  the  severity  of 
the  pains  is  very  great,  or  it  is  deemed  advisable 
to  induce  deep  anaesthesia  for  the  performance  of 
an  obstetric  operation. 

3.  For  nervous  women  and  those  who  dread  pain, 
also  in  cases  w7hen  the  perinaeum  is  very  rigid, 
chloroform  should  be  used,  as  it  relaxes  the  peri- 
naeal  structures  and  so  is  most  beneficial. 

4.  "When  the  patient  becomes  excited  by  the  chloro- 
form, if  it  is  considered  really  essential  that  she 
should  be  anaesthetised,  it  must  be  pushed  to  com- 
plete narcosis. 

5.  "When  the  labour  is  protracted  and  the  patient  is 
to  be  kept  anaesthetic,  it  is  necessary  to  discontinue 
the  inhalation  from  time  to  time,  otherwise  an 
injurious  accumulation  of  the  drug  will  take  place. 

G.  "When  an  obstetric  operation  becomes  necessary 
deep  anaesthesia  must  be  obtained  (Charpentier). 

7.  When  heart,  lung,  or  kidney  disease  exists  in  a 
parturient,  the  production  of  anaesthesia  may  be 
dangerous,  and  its  advisability  must  be  settled 
upon  the  same  general  principles  which  guide  us 
in  deciding  upon  like  cases  in  surgical  anaesthesia. 


ANAESTHETICS    IN    OBSTETRIC    PRACTICE.  157 

8.  It  is  necessary  when  the  patient  is  kept  semi- 
narcotised  to  carefully  guard  against  over- disten- 
sion of  her  bladder. 

9.  It  is  inexpedient  to  awaken  the  patient  to  con- 
sciousness by  artificial  means,  e.g.,  slapping  with 
a  wet  towel. 

10.  "When  the  foetal  head  bears  on  the  perineum,  give 
the  anaesthetic  more  freely,  as  it  relieves  the  in- 
creased pain  and  also  relaxes  the  maternal  passages, 
and  lessens  the  danger  of  tearing  the  perinaeum. 

11.  If  the  patient  is  depressed  or  the  pains  are  slug- 
gish during  the  administration,  an  occasional  stimu- 
lant may  be  administered. 

12.  In  cases  where  the  anaesthetic  appears  to  inter- 
fere with  the  progress  of  labour,  it  may  be  neces- 
sary to  suspend  its  use  for  a  time  and  re-apply  it 
after  an  interval,  or  even  to  withdraw  it  altogether. 
If  a  meal  has  been  recently  partaken,  avoid  chloro- 
form, the  sickness  likely  to  follow  will  impede 
delivery. 

Objections. — These,  although  strenuously  urged  by 
some,  are  probably  more  theoretical  than  real. 

1.  Chloroform  is  said  to  increase  the  mortality  alike 
among  mothers  and  children. 

Statistics  certainly  negative  this  statement.  It  has 
been  averred  that  the  danger  to  the  parturient  is  in 
direct  proportion  to  the  amount  of  pain  experienced, 
and  since  chloroform  minimises  this,  it  lessens  the  ac- 
tual danger  of  childbirth. 

2.  It  is  asserted  that  it  protracts  the  labour. 

Unless  pushed  to  the  degree  of  deep  narcosis  chloro- 
form does  not  interfere  with  uterine  contractions.  In 
experimental  researches  upon   animals  this  point  has 


158  ANESTHETICS. 

been  fully  proved,  and  lias  recently  been  corroborated 
in  a  striking  manner  by  Dr.  Milne  Murray,  of  Edinburgh. 
Deep  narcosis  renders  the  voluntary  abdominal  mus- 
cles lax,  and  so  interferes  with  expulsive  efforts.  Very 
deep  narcosis  also  paralyses  the  uterine  muscular  tissue. 
On  the  other  hand  a  womb,  exhausted  by  frequent  and 
ineffectual  contractions,  will  often  under  chloroform 
regain  tone  and  resume  vigorous  expulsive  movements. 

3.  Rupture  of  the  perinseum  is  said  to  follow  more 
commonly  when  chloroform  is  used. 

I  have  never  seen  satisfactory  proof  of  this  allegation, 
and  can  find  no  valid  reason  why  such  an  accident 
should  be  associated  with  the  anesthetic  state. 

4.  Complications  are  asserted  to  be  more  liable  to 
occur  when  it  is  used. 

This  point  was  carefully  investigated  by  the  Chloroform 
Committee  of  the  Royal  Medico- Chirurgical  Society,  and 
it  was  found  that  chloroform  when  properly  administered 
does  not  predispose  to  inflammation,  puerperal  convul- 
sion, apoplexy,  or  other  mishap  ;  indeed,  as  it  promotes 
relaxation  of  the  maternal  passages,  it  is  beneficial. 

Opinions  differ  as  to  whether  it  predisposes  to  imper- 
fect contraction  of  the  uterus  and  so  to  post  partum 
haemorrhage.  This  question  is  greatly  influenced, 
firstly  by  the  degree  of  narcosis  arrived  at,  and  secondly 
by  the  length  of  time  allowed  to  elapse  before  its  use,  as 
well  as  that  during  which  it  is  employed.  Prolonged 
use  of  small  doses  may  be  more  harmful  in  this  respect 
than  deep  narcosis  arrived  at  rapidly  and  not  main- 
tained for  more  than  a  few  minutes.  It  is  also  highly 
important  that  the  patient's  respiration  should  be  free 
and  unhampered  by  her  posture.  Lactation  is  not  in- 
juriously affected ;  the  child  is  in  no  way  injured. 


METHOD    OF    EXHIBITION.  159 

Convalescence  is  not  only  not  delayed,  but  is  in  poiut 
of  fact  actually  hastened  by  the  use  of  chloroform. 
This  statement  is  made  upon  good  authority,  and  is 
probably  explained  by  the  fact  that  by  the  use  of  chloro- 
form the  nervous  system  is  protected  from  shock. 
(Sansom). 

Method  of  exhibition. — "When  chloroform  is  em- 
ployed the  open  method  probably  is  the  best,  admitting 
as  it  does  plenty  of  air,  the  countenance  being  readily 
seen.  A  little  chloroform  may  be  sprinkled  upon  a 
piece  of  folded  lint,  or  on  a  towel.  Some  practitioners 
let  the  patient  hold  a  piece  of  lint  or  a  cup  inhaler  so 
that  when  she  grows  drowsy  the  improvised  inhaler 
drops  from  the  hand.  Care  must  be  taken  that  the 
face  does  not  fall  over  the  chloroformed  cloth,  or  the 
breathing  become  impeded  by  the  pillow  or  bedding. 

"When  deep  anaesthesia  is  required  it  is  best  to  have 
a  skilled  administrator."     (Chloroform  Committee). 

When  chloroform  or  the  A.  C.  E.  mixture  is  adminis- 
tered by  a  person  who  gives  himself  up  solely  to  this 
duty,  the  use  of  Junker's  inhaler  fitted  with  the  flannel 
cap  (see  p.  114)  possesses  the  advantage  that  there  is 
less  escape  of  vapour  into  the  room,  the  air  of  which 
keeps  purer.  When  a  less  elaborate  and  more  portable 
apparatus  is  desired,  Krohne's  cone  with  respiration 
indicator  is  very  good,  as  it  allows  the  administrator  to 
see  the  breathing  is  beiug  properly  performed,  even 
when  the  posture  of  the  patient  renders  it  difficult  for 
him  to  see  the  thoracic  movements. 

In  the  First  Stage  of  Labour,  chloroform  or  the 
A.  C.  E.  mixture,  if  required  at  all,  should  be  given 
intermittently  and  in  small  quantities.  As  a  rule 
the   first    stage    of    narcosis   is    deep    enough.       The 


160  ANESTHETICS. 

patient  is  conscious,  but  only  slightly  alive  to  painful 
sensations.  If  any  excitement  and  disorderly  con- 
duct follow,  the  patient  must  be  allowed  to  recover  her 
self-control.  Some  persons  need  more  chloroform  than 
others,  so  that  the  administrator  must  decide  each  case 
upon  its  own  merits  and  further  must  be  guided  by  his 
own  observations,  and  not  influenced  solely  by  the 
patient's  cry  of  "  Give  me  some  more."  Women  fre- 
quently repeat  this  phrase  when  almost  unconscious 
and  unaware  of  preferring  any  request. 

In  the  Second  Stage,  chloroform  should  be  given 
only  during  the  pains,  and  then  merely  to  slight  nar- 
cosis, since  the  woman  needs  the  use  of  the  abdominal 
muscles.  At  the  stage  of  labour  when  the  head  is 
traversing  the  perinseum,  deeper  narcosis  is  needed  to 
relax  the  soft  parts,  whilst  at  the  last  as  the  head 
emerges  through  the  vulva,  chloroform  should  be  freely 
administered. 

"When  Instrumental  Procedure  is  requisite  deeper 
narcosis  is  needful,  and  especial  caution  is  required  in 
order  to  prevent  the  patient  being  made  simply  ex- 
cited and  rigid,  a  condition  alike  dangerous  to  the 
mother  and  child.  In  this  stage  the  anaesthetic  must 
be  pushed  and  true  anaesthesia  obtained. 


Obstetric  Operations. 

For  Turning  and  instrumental  deliveries,  if  an 
anaesthetic  is  employed,  deep  anaesthesia  is  requisite 
and  may  either  be  obtained  by  chloroform,  the  A.  C.  E. 
mixture  or  ether.  The  London  Committee  approved 
the  first  named,  but  mainly  on  account  of  the  greater 


AFTER-EFFECTS.  161 

ease  with  which  it  was  then  exhibited.  Since  our 
modern  appliances  for  giving  ether  are  so  improved 
this  reason  can  have  no  weight.  In  deep  narcosis 
from  chloroform  the  parturient  is  placed  in  the  same 
danger  as  for  any  surgical  operation.  It  is  sometimes 
urged  against  ether  that  it  does  not  relax  the  uterine 
tissue  so  effectually  as  chloroform.  If  this  objection  is 
valid  it  tells  also  the  other  way,  as  hemorrhage  would 
under  such  circumstances  be  less  likely  to  be  severe. 
The  ether  effect  passes  off  more  rapidly. 

The  A.  C.  E.  mixture  is  largely  used  in  operative 
obstetric  practice  and  answers  remarkably  well.  It  is 
best  given  in  Junker's  inhaler  or  from  Krohne's  cone. 

For  extraction  by  forceps  narcosis  sufficiently 
deep  to  keep  the  patient  quiet  is  needed. 

Craniotomy.— The  narcosis  must  be  deep. 

Hour-glass  contraction.— Retained  placenta, 
Here  complete  relaxation  is  necessary  and  so  the  anes- 
thetic must  be  pushed. 

Puerperal  convulsions. — Chloroform  is  indicated 
in  all  cases  of  convulsions  associated  with  labour. 
It  is,  however,  contra -indicated  in  apoplectic  seizures. 


After  Effects. 

Vomiting  is  rare  ;  faintness,  excitement,  headache 
have  sometimes  been  manifested,  but  as  a  rule  few  un- 
pleasant results  follow  the  use  of  chloroform  for  child- 
birth. 


M 


162  ANESTHETICS. 


CHAPTER   IX. 

Anesthetics  in  Special  Surgery. 

Brain  Surgery. — The  method  which  answers  best 
when  the  brain  itself  is  made  the  subject  of  operation, 
is  to  administer  a  dose  of  morphine,  beneath  the  skin, 
either  one  quarter  of  an  hour  before  the  operation,  and 
subsequently  to  administer  chloroform,  or  to  inject  the 
morphine  as  soon  as  the  chloroform  has  deadened  the 
patient's  sensibility.  It  is  necessary  to  get  the  patient 
completely  anaesthetised,  but  when  once  this  is  achieved 
very  little  more  chloroform  is  needed.0  Ether  pro- 
duces too  much  vascular  excitement  in  the  meninges 
and  brain  substance,  and  so  is  contra-indicated  in 
these  cases. 


Anesthetics  in  Ophthalmic  Practice. 

Since  the  introduction  of  cocaine,  many  operations 
about  the  eye  are  performed  without  the  employment 
of  general  anaesthesia.  The  extreme  steadiness  and 
immobility  needful  in  these  delicate  operations  require 
very  deep  narcosis,  and  so  it  is  the  administrator's 
duty  to  push  whatever  vapour  he  is  using  until  profound 
narcosis  is  obtained.     The  operator  must  not  be  allowed 

*  I  am  indebted  to  my  friend  and  colleague  Mr.  Victor  Horsley, 
F.R.S.,  for  this  method  in  Brain  Surgery;  I  have  employe!  it  for  these 
ca.-ea  with  great  success. 


ANAESTHESIA   FOR    OPERATIONS.  163 

to  commence  his  manipulation  until  the  patient  is  not 
only  absolutely  unconscious  and  flaccid,  but  shows  not 
the  slightest  inclination  to  cough,  vomit,  or  struggle. 
It  must  be  kept  in  constant  remembrauce,  that  the  very 
salvation  of  the  eye  depends  upon  the  unflinching  im- 
mobility of  the  person  of  the  patient.  The  nature  of 
the  anaesthetic  used  is  of  less  importance  than  is  the 
way  in  which  it  is  employed. 


Anaesthesia  for   Operations  about  the    Mouth,  Jaws, 
and  eespiratory  tract. 

Chloroform  is  preferred  (1)  because  under  its  use  the 
narcosis  is  deeper  and  more  prolonged ;  (2)  its  vapour 
is  not  easily  ignited  ;  (3)  it  can  be  conveniently  given 
through  the  nose  and  so  can  be  given  without  being  an 
inconvenience  to  the  operator. 

In  the  removal  of  sequestra  from  the  jaws,  excision  of 
epuhdes,  tapping  antral  abscess,  etc.,  no  very  deep 
narcosis  is  requisite  and  the  patient  may  be  kept  suffi- 
ciently  quiet  by  the  use  of  chloroform  given  by  the 
open  method. 

During  the  removal  of  the  upper  jaw,  the 
patient  must  be  kept  deeply  under  the  anaesthetic  for 
the  skin  incisions,  and  this  may  be  done  by  first  nar- 
cotising by  the  open  method  and  by  subsequently 
keeping  up  the  supply  of  chloroform  through  a  tube 
introduced  into  the  free  nostril  and  fed  with  chloro- 
formised  air  from  a  modified  Junker.  When  the  skin 
flaps  and  soft  parts  are  freely  divided  and  dissected  up, 
the  patient  must  be  allowed  to  recover  sufficiently  to 
cough  and  so  prevent  blood  entering  the  larynx,  al- 

m2 


164  ANAESTHETICS. 

though  he  must  be  sufficiently  anaesthetic  not  to  struggle. 
The  management  of  these  cases  needs  constant  care 
and  some  judgment.  The  dangers  the  chloroformist 
has  to  guard  against  are — entrance  of  blood,  teeth,  por- 
tions of  growth,  spicules  of  bone,  etc.,  into  the  larynx  ; 
the  patient  passing  into  the  second  stage  of  chloro- 
formisation  and  growing  restive,  excited  and  so  violent 
as  to  interrupt  the  progress  of  the  anaesthetic.  He 
should  see  that  the  haemorrhage  is  directed  out  of  the 
mouth,  that  the  tongue  is  not  allowed  to  fall  back,  that 
the  air  enters  and  leaves  the  glottis  freely.  If  the 
patient's  respiration  is  embarassed  from  entrance  of 
blood  into  the  air  passages,  the  tongue  must  be  drawn 
right  out  of  the  mouth,  all  blood  mopped  away,  and 
failing  relief  from  this,  laryngotomy  must  be  performed 
and  the  tube  sucked  free  from  clots,  etc.  Inversion 
may  be  needed. 

Removal  of  the  lower  jaw  may  often  be  done 
almost  completely  while  the  patient  is  under  ether, 
chloroform  being  administered  only  just  at  last  when 
in  the  course  of  the  operation  the  mouth  is  opened. 
This  is  an  admirable  method. 

In  excision  of  the  tongue.— Chloroform  admin- 
istered through  a  nasal  tube  should  be  relied  upon  and 
much  the  same  precautions  with  regard  to  haemorrhage 
taken,  as  in  anaesthetising  for  removal  of  the  jaws. 
"When  much  haemorrhage  occurs,  the  patient  must  be 
guarded  from  deep  narcosis.  By  the  use  of  Dr.  F. 
Hewitt's  gag,  p.  114,  the  nasal  tube  can  be  dispensed 
with. 

Staphyloraphy  is  best  performed  under  chloro- 
form, which  is  preferably  administered  through  the  nostril. 
Care  must  be  taken  that  the  nasal  tube  does  not  get  into 


KECTAL  ETHERISATION  IN  OEAL  SURGERY.      165 

the  operator's  way,  and  to  avoid  this  possibility,  a  flexible 
catheter  should  be  used.  The  haemorrhage  being,  as 
a  rule,  slight  and  easily  controlled,  there  is  no  parti- 
cular fear  of  blood  trickling  down  the  trachea,  and 
further,  as  quietness  is  very  desirable  in  the  patient,  full 
surgical  narcosis  should  be  maintained.  However, 
with  careful  management  and  with  frequent  interrup- 
tion of  the  operation,  ether  or  the  A.  C.  E.  mixture  may 
be  used.  Warrington  Haward,  to  whose  powerful  ad- 
vocacy the  ether  propaganda  owes  so  much,  speaks 
highly  of  ether  in  staphyloraphy. 

Operations  on  the  respiratory  tract,  laryn- 
gotomy  or  tracheotomy  is  usually  performed  when 
the  patient  is  under  chloroform  as  the  rapid  movements 
under  ether  interfere  with  the  surgeon. 

Excision  of  the  larynx,  thyrotomy  requiring 
a  preliminary  tracheotomy,  may  be  performed,  chloro- 
form being  given  by  sprinkling  it  on  a  flannel  stretched 
across  a  funnel,  connected  with  a  Halm's  tube,  or  by 
directing  a  catheter  over  the  outlet  of  the  Halm's 
tube,  and  pumping  through  it  chloroformed  air  from 
a  Junker's  inhaler.     An  alternative  is  given  below. 


Kectal  Etherisation  in  Oral  Surgery. 

My  experience  of  this  method  is  so  far  so  favourable 
that  I  should  say  for  removal  of  the  tongue,  the  jaws, 
and  for  staphyloraphy,  especially  for  excision  of  the 
larynx,  the  rectal  etherisation  is  far  more  convenient 
for  the  operator,  and  more  effectual  in  the  anaesthesia 
it  produces  than  the  plans  named  above  in  which 
chloroform  is  used.      The  operation  can  be  proceeded 


166  ANESTHETICS. 

with  without  a  break,  and  the  after-effects  to  the  patients 
appear  as  a  rule  to  be  less  troublesome  and  less  lasting 
than  when  the  anaesthetic  is  given  by  the  air  passages. 
In  cases  in  which  much  blood  is  likely  to  be  thrown  into 
the  buccal  cavity,  careful  watch  will  have  to  be  taken 
that  it  is  efficiently  sponged  out,  and  does  not  enter  the 
windpipe.  If  the  anaesthetist  is  engaged  in  watching 
the  apparatus  at  the  foot  of  the  operating  table,  another 
observer  should  be  stationed  at  the  head  to  watch  this 
point  closely. 

In  all  these  cases  the  inverted  posture  of  Langenbeck 
may  be  usefully  employed.  The  method,  however, 
admirable  as  it  is,  is  certainly  not  free  from  dangers 
peculiar  to  itself. 


Eemoval  of  Post-Nasal   Adenoids. 

Growths  in  the  post -nasal  region,  when  removed 
through  the  mouth,  give  rise  to  troublesome  bleeding. 
Chloroform,  preferred  by  many  surgeons,  possesses  the 
disadvantage  that  the  patient  remains  longer  under 
its  influence,  and  so  it  is  less  easy  to  avoid  blood  enter- 
ing the  air  passages.  The  additional  time  is  by  some 
deemed  an  advantage,  as  it  permits  of  longer  manipu- 
lation in  the  mouth.  I  have  found  that  when  it  is 
undesirable  to  use  chloroform,  the  A.  C.  E.  mixture  in 
succession  to  gas  answers  fairly  well  in  these  cases.  It 
does  not  excite  as  much  haemorrhage  as  ether,  and  the 
patient  can,  if  necessary,  be  again  and  again  anaesthe- 
tised, after  emptying  his  mouth  of  blood,  until  the 
operation  is  complete.  By  this  method  there  is  not 
much  fear  of  blood  being  sucked  into  the  larynx. 


ANAESTHETICS   IN    DENTAL    SURGERY.  167 

Ether  possesses  the  disadvantage  of  producing  much 
congestion,  and  so  increases  to  an  annoying  degree  the 
haemorrhage  incident  upon  operations  for  the  removal 
of  post  nasal  growths.  Still,  if  properly  managed,  ether 
answers  very  well  for  these  cases.  Of  course  where  the 
cautery  is  used  in  the  nasal  passages,  ether  must  not 
be  used. 


Anesthetics  in  Dental  Surgeey. 

The  operations  for  which  an  anaesthetic  is  usually 
needed  are  : — 

Extraction  of  teeth. 

Lancing  the  gums,  and  tapping  the  antrum. 

Extirpation  of  the  dental  pulp. 

Filling  when  the  dentine  is  abnormally  sensitive. 

In  tooth  extraction,  nitrous  oxide  gas — alone,  or  with 
ether  after  the  manner  introduced  and  advocated  by 
Clover — is  the  safest  and  most  convenient  anaesthetic. 

The  administrator  stands  to  the  left  side  of  the 
patient  and  carefully  fixes  his  prop  (gag)°  either  on  the 
side  opposite  that  from  which  the  teeth  are  to  be 
drawn,  or  between  the  central  mcisors — thus  allowing 
room  on  each  side.  The  patient  is  then  anaesthetised 
(see  section  "Nitrous  Oxide"),  and  when  quite  un- 
conscious, the  face-piece  is  withdrawn,  and  the  patient's 
head  steadied  and  moved  into  the  most  convenient  pos- 
ture for  the  dentist.  Care  has  to  be  taken  that  the  tooth, 
or  a  fragment  from  a  broken  forceps,  does  not  fall  back 
into  the  larynx,  and  that  the  tongue  is  not  pushed  back 
by  the  operator  and  the  patient's  breathing  impeded. 

*  In  this  case  great  care  must  be  taken  to  avoid  the  teeth  being 
loosened  or  forced  out  of  their  sockets  by  the  prop. 


168  ANESTHETICS. 

As  a  rule,  it  is  inadvisable  to  administer  gas  twice  to 
the  same  patient  at  one  sitting,  but  if  such  a  thing  is  done 
warning  of  probable  after-headache  should  be  given. 

"Where  prolonged  anaesthesia  is  required,  ether  may 
be  given,  and  the  ordinary  precautions  taken  as  for 
etherisation  in  general  surgery.  Chloroform  should 
never  be  given  to  a  patient  sitting  upright  in  a  dental 
chair.  If  it  is  deemed  wise  to  employ  that  agent,  the 
patient  should  be  seen  at  his  own  home,  and  in  bed, 
and  the  anaesthetic  administered  with  the  usual  caution. 

For  special  dangers  of  anaesthetics  in  dental  surgery 
see  Nitrous  Oxide,  under  accident,  p.  57,  and  Accidents 
of  Anaesthesia,  Chap.  X. 


Thoracic  Surgery. 

In  the  surgical  treatment  of  empyema  some  diffi- 
culty frequently  arises  in  the  choice  of  the  anaesthetic. 
Chloroform  has  in  a  good  many  instances  caused  dan- 
gerous and  even  fatal  results  from  syncope,  while  ether 
sets  up  severe  cough  and  respiratory  distress.  The 
A.  C.  E.  mixture  when  it  can  be  borne  answers  well, 
but  must  be  given  in  a  very  dilute  vapour  ;  even  then 
it  is  liable  to  provoke  distressing  cough.  This  state  of 
things  is  rendered  worse  by  the  lateral  posture  which 
the  exigencies  of  the  operation  may  require.  It  is 
sometimes  a  good  plan  in  very  severe  cases,  i.e.,  when 
grave  fears  exist,  owing  to  the  condition  of  the  heart 
and  lungs,  to  push  the  anaesthetic  to  only  the  first  stage, 
as  far  as  possible  maintaining  a  state  of  analgesia,  and 
always  stopping  short  of  true  anaesthesia.  To  combat 
these  difficulties  I  have  employed  the  method  of  rectal 


ANAESTHESIA    IN   ABDOMINAL    SURGERY.  169 

etherisation  (q.  v.)  in  thoracic  surgery  and  have  been 
pleased  with  the  results  especially  in  the  case  of 
children.  When  the  empyema  communicates  with 
a  bronchus  great  care  must  be  taken  that  the  patient 
does  not  become  sufficiently  deeply  narcotised  to  hinder 
free  coughing  up  of  the  pus  in  his  lungs.  Any  ten- 
dency to  cyanosis  should  be  accepted  as  a  signal  to  lessen 
the  depth  of  the  narcosis,  and  provided  care  has  been 
taken  in  the  initial  etherisation  this  is  easily  effected  in 
the  rectal  method. 


Anesthesia  in  Abdominal  Surgery. 

Complete  relaxation  of  the  recti  and  other  abdominal 
muscles  is  imperative ;  great  quietude  and  freedom  from 
hurried  respiration,  coughing,  and  vomiting,  are  also 
necessary  for  operations  upon  the  abdominal  parietes 
or  viscera.  To  ensure  these  points,  chloroform,  the 
A.  C.  E.  mixture,  or  methylene,  are  most  suitable. 
During  the  incision  through  the  parietes,  the  patient 
must  be  kept  fully  under  the  anaesthetic,  subsequently 
a  lesser  degree  of  narcotism  is  needed  until  the  final 
skin  sutures  are  put  in,  when  deeper  anaesthesia  will 
again  be  requisite.  Great  care  must  be  taken,  however, 
that  the  patient  is  not  allowed  to  recover  sufficiently 
for  the  supervention  of  vomiting.  In  cases  in  which  a 
large  tumour  or  collection  of  fluid  or  gas  is  removed 
from  the  abdomen,  and  the  heart — previously  displaced — 
is  allowed  suddenly  to  right  itself,  there  is  especial 
danger  of  syncope,  and  precaution  against  this  must  be 
taken. 


170  ANESTHETICS. 


Rectal  Surgery. 

All  operations  about  the  anus  and  rectum  are  not 
only  very  painful,  but  excite  reflex  straining  and  spasm. 
In  anaesthetising  for  such  operations,  profound  narcosis 
is  needful.  The  combination  of  gas  and  ether  in  most 
cases  answers  well,  although  it  is  necessary  to  give 
enough  ether  to  induce  absolute  muscular  flaccidity, 
snoring  respiration,  and  widely  dilated  pupils — and 
further,  to  maintain  deep  narcosis  to  the  end  of  the 
operation. 


ACCIDENTS    OF    ANAESTHESIA.  171 


CHAPTEE   X. 

The    Accidents   of    Anaesthesia,  and    How  to    Treat 

Them. 

I.  Those  connected  with  Respiration. 

Foreign  bodies  may  become  loose  in  the  mouth, 
and  either  get  sucked  into  the  larynx  and  thence  enter 
the  trachea,  or  become  impacted,  and  set  up  laryngeal 
spasm. 

False  teeth.— Small  plates  are  especially  danger- 
ous, whilst  obturators  and  pivots  may  also  become 
sources  of  peril.  During  operation,  teeth  or  pieces 
chipped  off  teeth  may  fall  back,  and  even  portions  of 
epitheliomatous  or  other  growth,  blood  clot,  vomited 
undigested  solid  food,  gags,  portions  of  snapped  off 
forceps,  and  bits  of  sponge,  may  obstruct  breathing. 
When  the  tongue  is  partially  removed,  the  stump  is 
liable  to  fall  back  and  cover  the  glottis,  and  similarly 
after  removal  of  a  portion  of  the  lower  jaw,  the  whole 
tongue  may  be  carried  back  by  its  own  weight.  This 
may  also  occur  in  deep  narcosis,  even  when  the  jaw 
is  intact.  The  finger  inserted  in  the  mouth  during 
tooth  extraction,  often  pushes  the  tongue  right  back, 
and  unless  this  is  noticed  and  remedied,  complete 
occlusion  of  the  air -way  occurs. 

Precautions. — Kemove  all  loose  bodies  from  the 
mouth  before  operation.  Let  the  patient  avoid  any 
solid  food  on   the  day  of  operation.      Never   operate 


172  ANESTHETICS. 

again  until  the  first  tooth  extracted  is  known  to  be  out 
of  the  mouth  ;  and  be  careful  that  the  forceps  are  freed 
from  the  tooth  just  removed,  before  employing  it  again. 
Gags  and  sponges  must  be  securely  tied  to  a  long 
string.  When  possible,  the  head  should  be  placed  on 
its  side,  to  obviate  the  effect  of  the  weight  of  the  tongue 
in  carrying  it  back,  and  also  to  facilitate  the  expulsion 
of  blood.  Sometimes  a  Carter's  oral  spoon  held  in  the 
mouth  during  tooth  extraction  prevents  teeth  flying 
back  and  being  drawn  into  the  larynx. 

Vomited  matters. — -When  through  the  exigencies 
of  the  case  or  through  inadvertence,  food  has  been 
taken  within  a  few  hours  of  the  administration  of  an 
anaesthetic  vomiting  is  pretty  sure  to  occur,  either  when 
the  operation  is  proceeding  or  as  the  patient  is  com- 
mencing to  regain  consciousness.  There  is  great 
danger  lest  vomited  matters  be  drawn  back  into  the 
larynx,  leading  to  asphyxia.* 

Respiration  may  also  be  hampered  by  the  posture 
of  the  patient,  by  pressure  upon  his  chest  from  instru- 
ments, assistants  leaning  upon  him,  or  by  tight  ban- 
daging. When  placed  prone  or  upon  the  side,  feeble 
people,  those  who  are  fat  or  emphysematous,  or  who 


*  The  following  case  illustrates  this  danger.  A  hospital  patient 
requiring  a  minor  operation  was  instructed  to  abstain  from  food  and 
I  resent  himself  in  the  evening  for  the  house  surgeon  to  operate.  The 
operation  was  performed — the  patient  being  skilfully  anaesthetised 
by  a  resident,  but  during  recovery  he  vomited,  and  large  masses  of 
undigested  meat  were  taken  from  the  mouth.  Asphyxia  being  im- 
minent laryngotomy  was  performed,  but  the  patient  died,  and  the 
necropsy  showed  a  mass  of  meat  had  entered  the  trachea,  and  lay  at 
its  bifurcation  occluding  the  bronchi.  It  transpired  the  man  had  in 
spite  of  explicit  directions  to  the  contrary  partaken  of  a  heavy  meat 
dinner  just  before  coming  to  the  hospital. 


TREATMENT.  173 

have  fluid  in  their  chests — one  lung  being  more  or  less 
hampered,  must  be  carefully  watched,  as  the  mechanical 
interference  with  breathing  in  these  cases  has  caused 
fatal  accidents. 

All  general  anaesthetics  eventually  paralyse  the  re- 
spiratory centre  in  the  medulla  oblongata,  and  so 
cause  cessation  of  breathing;  but  some  act  more  rapidly, 
and  provoke  spasm  of  the  glottis  by  the  impact  of  their 
too  strong  and  pungent  vapour  upon  its  delicate  mucous 
membrane.  In  this  way  no  air  enters  the  lungs,  al- 
though irregular  thoracic  movements  persist.  Spasm 
of  the  larynx  certainly  may  occur  from  ether  or  chloro- 
form vapour,  and,  it  is  stated,  from  nitrous  oxide  gas. 
As  a  rule  the  spasm  passes  rapidly  off,  being  relieved 
by  the  admission  of  air,  but  it  may  be  sufficiently 
severe  to  need  laryngotomy.  Chloroform  also  acts 
upon  the  larynx  in  another  way  whereby  the  air- 
passage  becomes  occluded ;  namely,  by  the  closure  of 
the  arytaeno-epiglottidean  folds.  In  this  case  respira- 
tory movements  persist  although  no  air  enters  the 
chest. 

Patients  may  be  actually  asphyxiated  by  the  admin- 
istrator excluding  all  air  ;  and  this  may  occur  with  any 
inhaler  unless  care  is  taken  and  the  colour  of  the  face 
watched. 

Treatment. — The  foreign  body,  if  still  free  in  the 
mouth,  should  be  dislodged  by  bending  the  head  for- 
ward and  sweeping  the  buccal  and  pharyngeal  cavities 
with  the  finger.  The  tongue  should  not  be  pulled 
forward,  otherwise  the  tooth,  or  whatever  it  is,  will 
enter  the  trachea.  Should  the  finger  feel  the  body 
fixed,  its  removal  must  be  attempted  with  oesophageal 
forceps  or  with  a  snare.      A  slap  on  the  back  often 


174  ANESTHETICS. 

helps  the  expulsion  of  the  offending  substance.  Inver- 
sion should  also  be  practised,  although  if  the  body  has 
already  passed  the  larynx  there  is  danger  of  its  impac- 
tion in  it  giving  rise  to  spasm.  Should  this  occur, 
or  should  suffocation  be  imminent  from  other  reasons, 
the  windpipe  must  at  once  be  opened  as  follows  : — - 

The  operator  feels  with  his  finger  for  the  cricoid  car- 
tilage, and  makes  his  incision  through  the  skin  and 
subcutaneous  structures  for  a  distance  of  two  and  a 
half  inches  vertically  downwards  making  the  cricoid 
cartilage  the  centre  of  this  incision.  The  assistant 
draws  open  the  wound  with  blunt  hooks,  taking  care  to 
pull  equally  on  the  two  sides,  as  it  is  all  important  that 
the  surgeon  should  have  the  middle  line  well  defined 
for  him.  Vertical  incisions  are  then  made  until  the 
deeper  structures  are  divided.  The  fascia  uniting  the 
edges  of  the  sterno -thyroid  muscles  has  to  be  sought 
and  divided.  This  done,  some  veins,  the  thyroid 
plexus,  come  into  view,  and  may  be  held  aside  with 
hooks,  but  should  they  be  large,  clamp  forceps  may  be 
used  to  secure  them  before  section,  and  they  can  later 
on  be  tied  at  leisure.  The  isthmus  of  the  thyroid  body 
may  present  and  hide  the  trachea,  but  after  dividing  its 
fascia,  it  can  readily  be  hooked  down  out  of  the  way. 
The  trachea  reached,  it  is  well  cleaned  with  a  blunt 
director  and  fixed  by  means  of  a  sharp  hook  introduced 
between  the  rings  to  the  side  of  the  middle  line,  and 
with  its  point  looking  upward.  The  trachea  is  then 
freely  opened  by  introducing  the  knife  from,  below,  and 
slitting  upwards  two  or  three  of  the  tracheal  rings,  even 
the  cricoid  cartilage  may  be  divided,  then  the  aperture 
held  freely  open  by  means  of  blunt  hooks.  Succussion, 
or  better,  tickling  the  tracheal  mucous  membrane  with 


TKEATMENT.  175 

a  feather  will  induce  violent  expiratory  efforts,  and  may 
provoke  expulsion  of  the  foreign  body  by  coughing. 
Further  measures,  such  as  the  introduction  of  fine  for- 
ceps, snares  and  so  forth,  are  matters  hardly  within  my 
province  to  describe.  The  main  object  of  tracheotomy 
in  these  cases  is  to  ensure  an  air- way  should  the  laryn- 
geal space  be  closed  by  spasm,  excited  by  the  foreign 
body  either  impacted  or  coughed  against  it.  The  opera- 
tion itself  greatly  increases  a  chance  of  the  patient's 
coughing  up  the  object,  because  the  artificial  opening 
is  insensitive  and  offers  an  unobstructive  outlet,  whereas 
the  sensitive  larynx  closes  as  soon  as  touched,  and  so 
effectually  prevents  the  coughing  out  of  the  foreign 
body.  After  the  foreign  body  has  been  removed  a 
small  dossil  of  wet  lint  should  be  placed  over  the 
opening. 

When  mechanical  impediment  to  respiration  is  not 
due  to  a  foreign  body  in  the  air  passages,  the  tongue 
must  be  drawn  forward  with  forceps,  until  it  protrudes 
well  out  of  the  mouth,  while  at  the  same  time  the  head 
is  thrown  back  to  straighten  the  respiratory  tract. 
This  treatment  will  usually  be  effectual  when  the 
tongue  or  larynx  is  the  cause  of  non- entrance  of  air. 

"When  spasm  of  the  larynx  results  from  adminis- 
tering an  anaesthetic,  and  persists  after  drawing  for- 
wards the  tongue  and  hooking  up  the  larynx,  laryngo- 
tomy  must  at  once  be  performed.  No  formal  operation 
is  needful,  the  surgeon  at  once  incising  the  crico-thyroid 
membrane  and  maintaining  open  the  aperture  so  made. 
It  is  suggested  by  some  that  inhaling  chloroform 
relaxes  the  spasm,  but  it  is  of  course  useless  to  adopt 
such  measures  if  the  rima  is  quite  occluded,  as  no 
vapour  will  enter,  and  valuable  time  is  being  lost. 


176  ANESTHETICS. 

If,  after  the  upper  air- ways  have  been  cleared  and 
rendered  patent  by  the  manoeuvres  above  cited,  the 
breathing  still  remains  unsatisfactory,  artificial  respira- 
tion must  be  at  once  practised  by  one  of  the  following 
methods. 


Sylvester's  Method.0 

The  tongue  being  drawn  forcibly  out  of  the  mouth, 
and  the  air-ways  seen  to  be  clear  of  obstruction,  the 
head  is  to  hang  back,  with  the  neck  extended,  and  the 
tongue  held  firmly  out  of  the  mouth.  The  operator 
stands  behind  the  patient  and  grasps  the  arms  near 
the  axillse  in  such  a  way  as  to  evert  them  and  render 
the  pectorales  majores  tense.  He  first  presses  the 
arms  into  the  sides  so  as  to  compress  the  thorax  and 
expel  air,  whilst  at  the  same  time  an  assistant  should 
make  pressure  upon  the  abdomen  to  prevent  the  in- 
creased intra -thoracic  pressure  from  forcing  down  the 
diaphragm.  Next,  he  firmly  drags  the  arms  away  from 
the  sides,  everting  them  and  lifting  the  patient  as  the 
arms  become  about  A5°  beyond  the  head ;  finally,  he 
carries  the  arms  back  to  a  line  with  the  head.  He 
pauses  to  allow  air  to  rush  freely  into  the  lungs,  and 
then  brings  the  arms  down  to  the  sides  as  before.  This 
process  he  repeats  twelve  or  sixteen  times  in  one 
minute.  The  way  the  arms  are  grasped  is  important. 
When  they  are  held  below  the  elbows,  it  is  not  possible 
to  open  out  the  chest  as  effectively  as  when  the  plan 
above  indicated  is  followed. 

*  The  method  described  is  modified  by  the  introduction  of  the 
essential  features  of  the  plans  proposed  by  Pacini  and  Bain. 


ACCIDENTS. 


177 


The  diagrams  given  below  illustrate  this  method  ot 
inducing  artificial  respiration. 


Fig.  27. — Artificial  Respiration — Inspiration. 


Fig.  28. — Artificial  Respiration — Expiration. 


Howard's  Method 

Can  be  usefully  employed,  supplementally  to  Sylves- 
ter's. It  is  also  of  value  when  the  patient's  chest  is 
rigid.  Dr.  Howard  insists  strongly  upon  the  full  ex- 
tension of  the  head  upon  the  trunk  that  the  air -ways 
may  be  thoroughly  straightened  out.  The  patient  is 
between  the  operator's  knees.  The  latter,  who  faces 
him,  applies  his  hands  so  as  to  grasp  the  free  margin 
of  the  thorax,  his  thumbs  resting  upon  the  xyphoid 
cartilage.  The  patient's  arms  are  drawn  above  his 
head.  The  operator  presses  upwards  and  inwards 
towards   the    diaphragm,    gradually  bending   over  the 


178  ANESTHETICS. 

patieDt  so  that  all  the  weight  of  his  body  aids  in  com- 
pressing the  thorax.  After  steady  pressure  for  some 
seconds  with  a  sudden  push-up  the  operator  throws 
himself  back  into  his  posture,  while  the  resiliency  of 
the  lungs  causes  their  expansion.  The  process  is  re- 
peated twelve  or  sixteen  times  a  minute. 

All  measures  in  artificial  respiration  must  be  adopted 
quietly,  firmly,  and  slowly ;  since  crowding,  hurry, 
fuss  and  inexpertness,  are  very  dangerous.  Life  may 
be  restored  after  an  hour's  artificial  respiration. 


II.  Accidents  connected  with  the  Heart  and  Blood- 
Vessels. 

Syncope  may  occur  as  the  result  of  fright,  or  be 
caused  by  sudden  impact  of  a  strong  vapour  upon  the 
air-passages.  This  occurs  in  the  early  stages  of  the 
administration,  and  is  shown  by  pallor  of  countenance 
and  failure  of  pulse. 

Treatment. — The  patient  should  at  once  be  placed 
supine,  the  legs  and  arms  raised,  and  the  head  dropped 
below  the  level  of  the  trunk  ;  all  clothing  loosened  ; 
smelling  salts,  liq.  ammonia  fort,  (with  caution),  or 
burnt  feathers  be  put  to  the  nostrils  ;  and  the  prae- 
cordium  rubbed  with  a  warm  hand.  Sulphuric  ether 
may  be  hypodermically  injected  over  the  heart,  and 
nitrite  of  amyl  capsules  be  smashed  and  the  patient 
made  to  inhale  the  vapour.  If  the  breathing  flag,  arti- 
ficial respiration  must  be  at  once  practised.  An  enema 
of  brandy — ^  ss.  in  3  ii.  of  warm  beef- tea  or  gruel  or 
starch — may  be  tried.  When  the  patient  has  recovered 
sufficiently  to  swallow,  hot  strong  coffee  with  a  tea- 
spoonful  of  Cognac  should  be  given.    The  most  stringent 


ACCIDENTS.  179 

injunctions  must  be  laid  down  that  the  horizontal  pos- 
ture be  maintained  until  the  heart  has  quite  recovered 
itself. 

Syncope  from  shock  occurring  later  on  may  arise 
from  prolonged  operation,  or  loss  of  blood,  or  over- 
taxing of  the  heart  due  to  respiratory  difficulties. 
Chloroform,  given  over  a  lengthened  period,  also  de- 
presses the  heart  and  may  determine  syncope. 

The  treatment  rehearsed  above  applies  also  to  these 
cases  ;  in  them  it  is  usually  more  common  to  find  a 
gradual  heart-failure  occurring,  and  giving  warning  of 
trouble.  Respiration  also  is  especially  liable  to  flag  at 
the  same  time  as  the  heart  fails.  It  is  especially  neces- 
sary to  have  resort  to  artificial  respiration  early,  both  on 
these  accounts  and  because  that  measure  even  by  itself 
will  frequently  steady  the  heart  and  restore  its  rhythm. 
In  all  syncopal  attacks,  while  the  above  measures  are 
being  adopted,  an  assistant  should  pour  cold  water  over 
the  face  and  chest,  and  dash  the  latter  with  a  towel-end, 
wrung  out  in  ice-cold  water. 

Apoplectic  seizures. — Besides  ceasing  from  all 
interference  and  placing  the  patient  supine,  little  can 
be  done,  and  directions  would  not  be  in  place  in  the 
present  manual. 

Epileptic   seizures The  patient  should  be  laid 

down,  his  tongue  be  guarded  from  being  bitten,  and  his 
clothing  loosened,  the  only  interference  justified  is  to 
be  directed  towards  restraining  the  patient  from  doing 
himself  any  injury. 

Hysterical  seizures  should  be  treated  in  a  similar 
way  to  that  indicated  above  (epileptic  seizures). 


n  2 


180  ANAESTHETICS. 


CHAPTEE   XI. 

Local  Anaesthesia. 

It  has  been  sought  to  obtain  local  anaesthesia  without 
disturbance  of  the  mental  faculties,  and  this  object  has 
been  consummated  with  partial  success  in  three  ways. 

(1)  By  drugs  painted  and  injected  at  the  situation 
desired  to  be  rendered  anaesthetic.  (2)  By  cold.  (3) 
By  electricity. 

The  most  usual  means  of  producing  local  anaesthesia 
by  drugs  is  the  use  of  cocaine.  This,  the  active  prin- 
ciple of  the  leaves  of  Erythroxylon  Coca,  a  plant  culti- 
vated in  Bolivia,  Peru,  the  Andes,  and  Argentina,  has, 
since  1880,  come  into  use  for  producing  local  insensi- 
bility to  pain.     It  is  employed  commonly  in  two  ways  : 

a,  as  a  paint  over  mucous   or   cutaneous   surfaces,  and 

b,  by  subcutaneous  injection. 

Physical  Properties,  Preparations,  etc 

The  Erythroxylon  Coca  (cuca)  leaves  have  been  known 
for  very  many  years  as  a  stimulant,  and  cocaine  was 
first  isolated  by  Gardeke  (1855)  who  called  it  erythroxy- 
Jine.  It  was  rediscovered  in  1857  by  S.  11.  Percy  of 
New  York,  who,  besides  isolating  the  active  principle  of 
erythroxyline,  described  the  property  it  possessed  of 
deadening  the  sensibility  of  the  tongue  ;  Niemann  in 
18G0  also  noticed  its  anaesthetic  properties.  Lossen  two 
years  later  recognised  the  true  composition  of  the  sub- 


PHYSICAL    PROPERTIES,  ETC.  181 

stance  and  gave  it  the  formula  C17H21N04.  It  was 
not  until  Karl  Roller,  in  1884,  induced  Dr.  Brettauer  to 
demonstrate  the  anaesthetic  properties  of  the  hydro- 
chlorate  of  the  alkaloid  before  the  Ophthalmological 
Congress  meeting  in  Heidelberg  that  it  became  gener- 
ally recognised  as  a  local  analgesic. 

The  alkaloid  cocaine  (C17H21N04)  has  a  bitter  taste  ; 
forms  crystals  ;  is  with  difficulty  soluble  in  water  (1  in 
700  or  more),  more  so  in  alcohol  (1  in  20),  freely  so  in 
chloroform  or  ether,  also  in  melted  vaseline,  castor  oil, 
&c.  Pure  cocaine,  or  the  hydrochlorate,  gives  no  colora- 
tion, or  a  very  faint  evanescent  yellow  one,  with  concen- 
trated cold  sulphuric  acid.  It  may  readily  be  recog- 
nised by  its  crystals,  which  are  colourless  monoclinic 
prisms.  Cocaine  readily  undergoes  chemical  changes 
in  its  composition,  so  that  solutions  for  use  should  be 
made  fresh  as  required.  "With  benzoic,  citric,  hydro- 
bromic,  sulphuric,  tannic,  oleic,  and  hydrochloric  acids, 
cocaine  forms  salts,  respectively,  the  benzoate,  citrate, 
hydrobromate,  sulphate,  tannate,  oleate,°  hydrochlorate, 
of  cocaine,  which  possess  the  advantage  of  being  easily 
soluble  in  water,  and  so  readily  employed  for  hypoder- 
mic injection.  Aqueous  solutions  of  these  salts  should 
not  be  kept  any  length  of  time,  as  they  are  liable  to 
become  contaminated  by  the  growth  of  a  fungus  which 
occasions  deleterious  effects  upon  the  patient.  The 
addition  of  boric  acid,  carbolic  acid,  or  chloroform  has 
been  suggested  to  prevent  such  fungoid  growth,  but 
these  cannot  be  relied  upon  to  promote  the  object  in 
view. 

Cocaine  acts  as  a  general  anaesthetic  when  so  over- 
whelming a  dose  is  taken  as  to  bring  the  animal  taking 

*  A  saturated  solution  of  cocaine  in  oleic  acid. 


182 


ANESTHETICS. 


it  to  the  point  of  death.  Its  true  action  is  that  of  an 
analgesic  and  this  is  due  not  to  the  vaso-rnotor  con- 
striction which  it  establishes,  but  to  its  influence  upon 
the  sensory  nerve  endings.  If  an  area  is  rendered 
anaemic  and  analgesic  by  cocaine,  the  subsequent  in- 
jection of  pilocarpine  will  abrogate  the  anaemia  while 
the  analgesia  remains  unaffected.  Arloing  has  shown 
the  same  thing  by  dividing  the  sympathetic  of  a  rabbit 
on  one  side,  the  animal  having  been  previously  cocain- 
ised, hypervascularity  could  thus  be  seen  to  exist  sim- 
ultaneously with  analgesia. 

The  hydrochlorate  is  the  salt  which  in  solution  is 
most  commonly  used  ;  it  forms  acicular  or  lamellar 
crystals.  It  is  soluble  in  half  its  weight  of  water,  but 
ireely  taken  up  by  glycerine  or  spirit,  and  unlike  co- 
caine is  insoluble  in  ether  or  fats.  It  is  liable  to  grow 
fungi.  The  proposed  addition  of  boric  or  other  anti- 
septics seems,  as  in  the  case  of  cocaine  itself,  useless  as 
a  means  of  checking  the  production  of  fungus. 


Physiological    Action    of    Cocaine    Upon    the   Heart 
and  Blood  Vessels. 

It  is  a  much  disputed  point  what  action  cocaine 
exercises  upon  the  lowest  organisms,  ferments,  infu- 
soria, &c,  but  it  would  seem  to  behave  as  a  true  anaes- 
thetic, producing  temporary  arrest  of  function  in  plants 
and  arrest  of  movement  in  the  lower  forms  of  animal 
existence  without  destroying  life  ;  if,  of  course,  the  dose 
employed  be  not  excessive  (Charpcntier). 

In  cold-blooded  animals  cocaine,  whether  applied 
to   the   heart  itself,  circulated   through   the   detached 


PHYSIOLOGICAL    ACTION    OF    COCAINE.  188 

ventricle,  or  injected  into  the  circulation,  slows  the 
rhythm,  and  depresses  the  beat,  finally  arresting  the 
heart  in  diastole.  Its  depressant  action  upon  the  heart 
is  shown  by  the  accompanying  cardiogram  (Fig.  27).  It 
was  taken  while  the  detached  heart  of  a  frog  was  per- 
fused with  a  competent  fluid  containing  cocaine  (1  in 
2000)  in  a  Eoy's  tonometer. 

Cocaine  also  interferes  with  cardiac  innervation,  de- 
creasing in  a  very  marked  degree  the  excitability,  for 
while  it  abolishes  "  make"  contractions,  "break"  con- 
tractions persist.  Although  both  auricles  and  ven- 
tricles are  influenced,  the  latter  are  more  interfered 
with,  and  cease  to  beat  before  auricular  rhythm  is 
arrested  (Van  Anrep). 

The  blood-vessels  are  but  little,  if  at  all,  affected 
by  cocaine  unless  it  be  applied  locally  as  a  paint,  and 
in  this  case  it  is  doubtful  how  far  the  action  is  really 
characteristic  of  the  drug. 

In  warm-blooded  animals,  an  initial  increase  in 
rapidity  of  the  heart's  beat  occurs,  the  heart's  action 
is  weakened,  but  usually  recovers  and  is  said  to  sur- 
vive the  cessation  of  respiration  (Van  Anrep).  Vagal 
inhibition  is  also  much  depressed  and  even  lost ;  blood 
pressure  is  greatly  lowered,  though  this  is  preceded  by 
an  initial  and  transient  increase  of  pressure. 

Cocaine  does,  however,  produce  a  very  marked  de- 
pressing action  upon  the  human  heart.  Many  persons 
after  even  small  doses  become  pallid  and  complain  of 
extreme  faintness,  while  the  heart's  action  grows  weak 
and  irregular,  the  radial  pulse  becoming  almost  indis- 
tinguishable, Blood  pressure  is  at  first  lowered  but 
subsequently  increased.  Cocaine  in  large  doses  (and 
we  must  remember  that  what  constitutes   a  large  dose 


184 


ANESTHETICS, 


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PHYSIOLOGICAL    ACTION    OF    COCAINE.  185 

varies  greatly  among  different  individuals)  renders  re- 
spirations more  rapid,  irregular  and  shallow,  and 
finally  will  asphyxiate  by  stopping  respiration  alto- 
gether. In  human  beings,  marked  dyspnoea  and 
breathlessness  may  follow  its  use. 

Convulsions  and  epileptiform  seizures,  due,  it  is  said 
(Durdufi),  to  vasomotor  irritation  producing  anaemia  of 
the  brain,  occur  after  toxic  doses.  Death,  according  to 
Mosso,  occurs  from  tetanic  contraction  of  the  dia- 
phragm. 

The  nervous  system  is  much  affected  by  cocaine. 
The  peripheral  nerves  of  sense  become  anaesthetic  over 
the  area  into  which  cocaine  has  been  injected,  the 
anaesthesia  extending  just  so  far  as  the  drug  traverses 
the  tissues.  Dastre  very  aptly  terms  cocaine  the 
"curare  "  of  the  sense  nerves.  Painting  over  the  skin 
may,  if  it  be  sufficiently  thin  to  permit  of  absorption, 
lead  to  a  like  result  but  in  lesser  degree,  since  but 
slight  absorption  occurs  by  cutaneous  surfaces.  The 
motor  nerves  are  usually  only  affected  by  large  doses, 
but  in  some  persons  comparatively  small  doses  have 
induced  paresis  or  paralysis  lasting  for  hours  or  even 
days.  Ptyalism  occurs  leading  to  dryness  of  the 
mouth  and  fauces.  Peristalsis  is  increased  and  vomit- 
ing and  borborygmi  follow  its  use.  The  other  secre- 
tions of  the  alimentary  tract  are  lessened.  The  urea 
and  phosphoric  acid  excretion  is  increased  by  it 
(Fleischer).  Cocaine  increases  destruction  of  tissue 
and  by  a  constant  repetition  of  this  process  leads 
finally  to  physiological  ruin.  Mydriasis  and  pro- 
ptosis  are  usual  among  warm-blooded  animals.  Upon 
warm-blooded  animals  cocaine  produces  great  hyper- 
excitation  of  the  muscular   system  and   marked   agi- 


186  ANAESTHETICS. 

tation,  a  large  dose  may  at  first  simulate  strychnine 
in  its  action,  causing  muscular  tremblings,  convulsive 
movements  and  spasms. 

Although  the  mind  at  first  will  remain  clear,  there  is 
usually  a  tendency  to  garrulity,  followed  by  great 
anxiety  and  feelings  of  unaccountable  distress.  Lan- 
guor, muscular  weakness,  and  lassitude,  will  then  take 
possession  of  the  patient,  who  becomes  haunted  by 
most  fantastic  hallucinations.  Some  persons  simply 
experience  slight  elation,  or  it  may  be  drowsiness,  but 
loquacity  is  the  most  usual  symptom. 

Cocaine  would  appear  to  produce  an  hyperexcitability 
of  the  spinal  cord  evincing  itself  in  muscular  tremblings 
and  twitchings  (Dastre)  ;  a  similar  condition  of  the 
medulla  accounts  for  the  vaso- motor  and  respiratory 
disturbance,  while  (Richet)  an  increased  excitability  in 
the  cortex  brings  about  convulsions,  &c.  In  fine  the 
effect  on  the  nervous  system  may  be  summed  up  in  the 
words  of  Dastre,  who  says  that  while  the  drug  para- 
lyses the  terminations  of  the  sensory  nerves,  it  excites 
all  other  parts — nerve  trunks,  spinal  cord,  medulla,  en- 
cephalon  and  sympathetic  chain. 

Cocaine  produces  at  first  a  slight  rise  in  body  tem- 
perature. 

It  is  eliminated  by  the  kidneys,  and  often  produces 
albuminuria  or  glycosuria,  accounted  for  by  Van  Anrep 
as  the  result  of  the  partial  paralysis  of  respiration, 
which  the  drug  occasions. 

No  attempt  has  been  made  to  describe  at  all  fully 
the  symptoms  which  characterise  poisoning  by  cocaine. 
These  are  bizarre  to  a  degree,  and  may  be  grouped  as 
(1)  more  or  less  heart  failure  with  a  remarkable  lower- 
ing of  blood  pressure,  paling  of  the  skin  and  mucous 


METHODS    OF    EMPLOYMENT.  1ST 

membranes ;  (2)  great  dyspnceic  distress  from  failure  of 
respiration ;  (3)  impairment  of  mental  faculties  and 
even  unconsciousness,  or  in  some  cases  catalepsy.  Con- 
vulsions may  occur,  or  a  loss  of  movement  in  various 
groups  of  muscles.  While  such  symptoms  usually  occur 
only  after  the  injection  of  a  considerable  dose  of  co- 
caine, they  may  follow  the  use  of  quite  a  small  quantity. 
Eetention  of  urine,  protracted  insomnia,  and  prolonged 
anorexia  are  also  recorded  (Kiimmer). 

Methods  of  Employment. 

1.  Instillation  into  the  eye. 

2.  Painting  over  mucous  surfaces. 

3.  Subcutaneous  injections. 

Whatever  method  be  adopted,  it  should  be  remem- 
bered that  a  dose  of  one  grain  will  in  a  large  number 
of  persons  produce  unpleasant  if  not  dangerous  sym- 
ptoms, half  a  grain  is  a  safer  dose,  though  even  this 
may  in  many  people  give  rise  to  trouble. 

As  a  paint,  20  per  cent,  solution  is  used,  weaker  pre- 
parations being  of  little  value  over  cutaneous  surfaces. 
Several  coats  are  necessary,  and  even  then  as  a  rule 
anaesthesia  will  not  extend  much  deeper  than  the  true 
skin. 

When  employed  for  mucous  surfaces,  especially  if 
there  be  any  likelihood  that  some  of  the  solution  may 
be  swallowed,  a  dilution  to  10  per  cent,  should  be 
adopted.  In  laryngoscopic  examination  Semon  uses  a 
20  per  cent,  solution,  painting  the  pharynx  with  it,  and 
this  he  finds  will  enable  the  patient  to  submit  tran- 
quilly to  prolonged  and  painful  laryngoscopy. 

In  ophthalmic  practice  it  is  well  to  instil  a  few  drops 


188  ANAESTHETICS. 

of  a  4  per  cent,  solution  into  the  conjunctiva,  repeating 
the  instillation  two  or  three  times  at  brief  intervals, 
and  then  waiting  from  five  to  ten  minutes  before 
operating.  If  the  manipulation  takes  long,  it  will  be 
necessary  to  repeat  the  process  from  time  to  time. 

Cocaine  is  also  employed  as  a  spray  in  an  atomiser, 
a  4  per  cent,  solution  being  used. 

Most  marked  effects,  both  local  and  constitutional, 
follow  the  use  of  cocaine  when  injected  hypodermically. 
Used  in  this  way,  its  action  is  more  rapid  and  more 
persistent  than  when  applied  as  a  paint  or  an  ointment. 
A  10  or  20  per  cent,  solution  is  usually  employed,  and 
from  2  to  5  minims  injected  at  the  site  of  operation. 
As  the  effect  may  pass  off  before  surgical  interference 
has  been  completed,  it  will  often  be  necessary  to  inject 
a  second  or  third  dose  during  the  operation.  Great 
care  must  be  taken  to  avoid  the  injection  entering  a 
vein,  as  it  is  probable  that  many  of  the  deaths  following 
the  use  of  cocaine  have  resulted  from  this  accident. 
From  five  to  ten  minutes  must  be  allowed  to  elapse 
after  injection  before  the  knife  is  inserted. 

Another  and  useful  method  of  administration  suit- 
able for  eye  work  is  the  placing  of  an  easily  soluble 
cocaine  tablet  (B.P.,  1885)  in  the  oculo-facial  fold  of 
the  conjunctiva. 

A  convenient  and  very  admirable  means  of  using 
cocaine  for  a  throat  spray  is  the  atomiser  figured  below, 
invented  by  W.  J.  Miller. 

Dr.  Leonard  Corning,  of  New  York,  proposes  yet 
another  method  of  using  cocaine.  He  first  marks  out 
with  crayon  the  superficial  veins,  to  obviate  a  possi- 
bility of  puncturing  them,  and  next  exsanguinates  the 
limb  with  an  elastic  bandage  and  Esmarch's  cord.     He 


METHODS    OF    EMPLOYMENT. 


189 


then  injects  superficially  three  to  five  drops  of  a  1  or  2 
per  cent,  solution  of  cocaine  hydrochl orate  immediately 
above  the  cord.  After  waiting  until  the  skin  is  anaes- 
thetic, he  injects  the  deeper  tissues  with  a  solution  of 
the  same  strength,  making  twenty  or  more  punctures 
according  to  the  area  to  he  rendered  insensitive.  Dr. 
Corning  then  applies  a  tourniquet  at  the  upper  limit  of 
the  anaesthetic  zone,  and  after  a  few  minutes  operates. 


Fig.  33. — Miller's  Atomiser. 

This  elaborate  procedure  is  based  upon  the  theory 
that  by  checking  the  venous  return,  he  prevents  a  de- 
portation of  the  anaesthetic  from  the  area  of  injection, 
while  dilution  of  the  drug  by  blood  is  also  lessened. 

In  other  words  it  is  assumed  that  cocaine,  instead  of 
being  rapidly  absorbed  into  the  circulation,  is  by  this 
method  able  slowly  to  permeate  the  tissues  and  exert 
its  paralysing  action  upon  the  peripheral  nerve  endings. 


190  ANESTHETICS. 

Dr.  Corning  also  employs  specially  constructed  rings 
and  haemostatic  clamps,  to  effect  the  same  "  incarcera- 
tion of  the  anaesthetic."  The  method  may  prove  ser- 
viceable when  cocaine  is  used,  hut,  as  we  have  indicated, 
the  employment  of  frequent  and  numerous  injections  of 
the  drug  are  not  devoid  of  danger.  In  estimating  the 
value  of  this  theory  also,  due  regard  must  be  had  to 
the  consideration  that  a  limb  surrounded  by  tight  cords 
or  a  tourniquet  is  thus  rendered  to  some  extent  insensi- 
tive, a  fact  which  may  account  for  Dr.  Corning  finding 
only  small  doses  of  cocaine  requisite.  Eobson,  Rummer 
and  others  who  have  tried  the  method  speak  well  of  it. 


Indications  for  the  use  of  Cocaine. 

Accounts  of  the   effects  differ  so  widely,  that  it  is 
wholly  impossible  to  do  more  than  indicate  the  class  of 
cases  in  which   cocaine  has  been  recommended  as  an 
efficient  anaesthetic. 
In  ophthalmic  jn'actice. 
Cataract  operations. 
Eemoval  of  foreign  bodies. 
Laceration. 
Iridectomy. 
Iridodesis. 
Sclerotomy. 

Slitting  up  the  canaliculi. 
To  this  list  some  surgeons  add  tenotomy  for  strabis- 
mus, and  extirpation  of  the  eyeball. 

Many  minor  eye  operations  have  been  purposely 
omitted.  Even  in  the  above  named  cases,  cocaine 
must   not  be   too   implicitly  trusted,  for   it  fails  with 


INDICATIONS    FOK    THE    USE    OF    COCAINE.  191 

some  individuals,  and  no  means  exist  which  enable  us 
to  determine  beforehand  when  it  will  succeed  or  fail. 
Panophthalmitis  has  followed  its  use  for  eye  operations. 
When  employed  for  extirpation  of  the  globe  or  teno- 
tomy, instillation  is  not  sufficient,  and  subconjunctival 
injection  is  necessary.  In  many  cases  patients  com- 
plain that  the  division  of  the  deeper  structures  causes 
much  pain  in  spite  of  cocaine.  The  presence  of  glau- 
coma is  a  contra-indication  to  the  use  of  cocaine,  in- 
deed according  to  Javal  its  constant  use  may  cause  a 
glaucomatous  condition. 

Although  advocated  for  operations  undertaken  to 
remove  foreign  bodies  from  the  cornea,  &c,  cocaine 
possesses  a  serious  drawback,  inasmuch  as  it  induces 
flaccidity  of  the  eyeball,  and  so  seriously  impedes 
operative  measures. 

Operations  about  the  Larynx,  Pharynx,  etc. — 

Ulceration  of  epiglottis,  scraping. 

Eemoval  of  polyps  from  larynx. 

Cutting  off  the  uvula. 

Catheterising  of  the  Eustachian  tubes. 

Eemoval  of  polyps  from  the  nose  or  ear. 

Cauterising  the  nasal  meatuses. 
Excision  of  the  Tongue  has  been  attempted,  but  without 
uniform  success. 

Abscesses,  boils,  and  carbuncles  may  be  opened,  and 
many  of  the  small  operations  classed  under  minor 
surgery  performed,  after  the  injection  of  cocaine. 

Operation  on  the  Urino- generative  Tract. — The  injection 
of  a  few  drops  of  a  two  per  cent,  solution  into  the 
urethra  is  said  to  render  catheterisation  painless,  but 
this  is  only  true  when  no  stricture  exists.  In  like 
manner  the  operations  of  lithotrity  and  litholapaxy  may 


192  ANESTHETICS. 

be  undertaken  after  an  injection  of  cocaine,  a  stronger 
solution  (five  per  cent.)  in  these  cases  will  better  answer 
the  purpose. 

7;?  Dental  Surgery. 

The  adjustment  of  clamps  and  separators. 
The  introduction  of  wedges. 
The  application  of  ligatures  for  the  rubber. 
The  manipulation  of  deep  cervical  edges  of  cavi- 
ties, whether  for  excavating,  filling,  trimming  or 
polishing. 
The  removal  of  tartar  in  pyorrhoea  alveolaris. 
The   modelling  of  sensitive  and  irritable  mucous 
membranes.     For  this  purpose  a  paint  of  a  10 
per  cent,  solution  is  used,  or  a  spray  of  2  or  4 
per  cent,  according  to  the  degree  of  sensibility 
manifested  by  the  parts. 
For  lancing  and  excising  gum-tissue. 
For    the   relief  of  pain   after   extraction,   though 
cocaine  is  usually  inadequate  to  accomplish  this. 
For  anaesthetising  pulps  before  extirpation. 
For  obtunding  sensitive  dentine   (results  are  not 
upon  the  whole  satisfactory). 
Many  observers   have   come   to  the   conclusion  that 
cocaine  is  a  failure  when  employed  to  effect  painless 
tooth  extraction  ;  small  doses  are  inadequate,  and  larger 
ones  too  frequently  give  rise  to  constitutional  derange- 
ment, which  is  always  prejudicial  and  often   alarming. 
As  a  rule,  a  grain  is  needed  to  anaesthetise  sufficiently 
to  permit  of  extraction,  and  ten  minutes  must  be   al- 
lowed to    elapse   before   applying  the  forceps.      Many 
patients   are  greatly  terrified   by  the  pricking  of  the 
hypodermic  syringe.     It  is  best  to  inject  by  three  punc- 
tures, one  on  the  lingual,  and  two  on  the  labial  aspect 


ACCIDENTS    ATTENDING    THE    USE    OF    COCAINE.  193 

of  the  tooth.  One  of  these  being  before,  and  one  be- 
hind  the  prominent  ridge  on  the  buccal  alveolus,  they 
will  correspond  to  the  roots  of  the  tooth  to  be  extracted. 
Messrs.  Cunningham  and  Hern  (Odont.  Trans.,  vol. 
xix.)  have  published  some  carefully  noted  cases  in 
which  cocaine  used  for  dental  purposes  has  given  rise 
to  very  unsatisfactory  if  not  alarming  results. 


Major  Opeeations. 

A  few  surgeons  have  undertaken  section  of  bones, 
clamping  of  haemorrhoids,  circumcision,  &c,  but  the 
successes  recorded  are  not  such  as  to  justify  the  use  of 
cocaine  in  these  operations,  unless  under  most  excep- 
tional circumstances.  In  all  these  cases,  repeated  and 
large  doses  of  cocaine  have  to  be  injected,  and  therefore 
we  cannot  be  sure  that  most  disastrous  constitutional 
effects  may  not  follow.  We  have  moreover  to  remem- 
ber, that  a  conscious  patient  is  always  more  or  less  a 
terrified  one,  and  so  not  in  a  favourable  frame  of  mind 
for  surgical  proceedings. 


Accidents    and    After-Effects  attending  the  use  of 
Cocaine,  with  their  Treatment. 

Severe  headache,  palpitation,  failure  of  the  heart, 
with  repeated  attacks  of  fainting,  precordial  pain,  and 
sensation  of  stifling,  and  inability  to  obtain  sufficient 
air,  may  be  experienced  even  after  small  doses. 

Tingling,  formication,  muscular  weakness,  vertigo, 
and  muscular  inco-ordination,  cold  sweats,  utter  pros- 

o 


194  ANESTHETICS. 

tration,  and  extreme  drowsiness,  are  also  not  uncommon 
symptoms.  Muscular  movements  almost  amounting  to 
convulsions  may  occur,  and  in  some  persons  persistent 
pendulous  oscillations  of  the  head  follow  the  use  of 
cocaine,  greatly  disturbing  the  operations  (dental), 
which  it  was  sought  to  achieve. 

Nausea  and  vomiting  sometimes  occur,  together  with 
cramping  pains  in  the  abdomen. 

These  untoward  symptoms  may  last  several  hours, 
or  pass  off  in  less  than  one  ;  they  may  be  slight,  or  so 
serious  as  to  cause  the  greatest  alarm. 

The  most  usual  after-effects  are  persistent  nausea, 
headache,  anorexia,  sleeplessness,  derangement  of  di- 
gestion, and  great  mental  depression. 

Treatment. — A  careful  watch  being  kept  over  the 
patient,  any  signs  of  heart  failure  or  insufficient  re- 
spiration must  be  at  once  treated.  The  patient  is  to 
be  placed  on  his  back,  his  arms  and  legs  raised,  his 
head  hanging  below  the  level  of  his  body,  and  all  cloth- 
ing loosened  about  the  neck,  chest,  and  waist,  while 
cold  air  is  admitted.  If  he  can  swallow,  a  teaspoonful 
of  sal  volatile  in  half  a  wineglass  of  water  should  be 
given  in  sips.  Strong  smelling  salts  should  be  sniffed, 
the  prfficordium  and  front  of  the  chest  dashed  with  a 
wet  cold  towel,  and  sinapisms  put  to  the  calves  of  the 
legs  and  nape  of  the  neck.  If  he  cannot  swallow, 
brandy  should  be  rubbed  with  a  finger  over  the  tongue, 
the  inside  of  lips  and  mouth.  Subsequently,  small 
doses — half  a  teaspoonful  of  brandy — should  be  given 
every  ten  minutes  until  pallor  disappears.  Nitrite  of 
amyl  in  capsules,  or  three  drops  on  a  handkerchief, 
may  be  held  to  the  nose. 

Warm  tea  and  hot  coffee  give  a  patient  comfort  after 


ACCIDENTS    ATTENDING    THE    USE    OF    COCAINE.  195 

the  syncope  lias  passed  off,  and  will  also  relieve  head- 
ache. 

As  a  rule,  absolute  quiet  in  the  prone  position,  with 
sal  volatile,  will  bring  a  patient  round  without  the  aid 
of  alcoholic  stimulants  and  the  more  heroic  treatment 
detailed  above. 

Should  respiration  become  greatly  hampered,  arti- 
ficial means  should  be  at  once  adopted  to  maintain 
breathing. 

Cocaine  has  no  distinct  antidote,  although  marked 
physiological  antagonism  exists  between  this  substance 
and  morphine.  Skinner  has  suggested  the  use  of 
atropine,  Mosso  that  of  chloral,  to  counteract  the  con- 
vulsive properties  of  cocaine. 

Several  fatal  cases  of  cocaine  poisoning  have 
occurred.  In  the  case  of  Professor  Colomnine's  patient 
23  gr.  proved  fatal,  this  dose  having  been  injected  into 
the  rectum  in  order  to  allow  of  scraping  an  ulcer.  In 
another  case  death  resulted  from  3  j.  of  a  20  per.  cent, 
solution  introduced  into  the  urethra  as  a  preliminary 
to  internal  urethrotomy.  Swabbing  out  the  larynx 
with  a  two  per  cent,  solution  has  also  proved  fatal  (Dr. 
W.  H.  Long  quoted  by  Dr.  J.  B.  Mattison).  This 
patient  was  aged  33  and  had  nearly  died  previously  as 
a  result  of  the  application  of  a  4  per  cent,  solution  to 
his  larynx.  Dr,  Mattison,  of  Brooklyn,  has  also  re- 
ported fifty  cases  in  which  death  seemed  imminent,  and 
in  several  cases  actually  followed  the  use  of  even  small 
doses.  These  cases  comprise  those  of  persons  for  whom 
cocaine  sprays,  injections,  painting  of  mucous  surfaces, 
instillations  in  the  conjunctiva,  had  been  used,  also  of 
stuffing  cocaine-moistened  pledgets  into  carious  teeth. 

Brucine,  and  a  substance  called  drumine,  have 

o2 


196  ANAESTHETICS. 

been  suggested  as  local  anaesthetics,  but  the  former  is 
little  used,  while  drumine  has  been  shown  to  be  oxalate 
of  lime  prepared  from  a  euphorbiaceous  plant  and  to 
be  devoid  of  anaesthetic  properties. 


Other  Methods  for  producing  Local  Anaesthesia. 


Fig.  31.— Dr.  Richardson's  Ether  Spray. 

Ether  Spray  (Dr.  B.  W.  Kichardson). — The  wood- 
cut explains  the  simple  mechanism  of  this  useful  con- 
trivance. A  bottle  containing  specially  prepared  ether,0 
is  traversed  by  an  air  current  propelled  by  a  hand  ball  so 
valved  as  to  admit,  but  not  allow  the  escape  of  air  save 
by  its  traversing  the  ether.  The  second  ball  which  is 
covered  with  net,  acts  as  a  reservoir.  Air  forced  into 
the  ether  atomises  it  through  a  delicate  tube,  causing 
it  to  escape  in  a  fine  spray.  Ether  impinging  upon 
the  skin  or  mucous  membrane  causes  so  rapid  an 
evaporation  from  its  surface,  that  its  heat  is  abstracted 

*  Richardson  recommends  anhydrous  ether,  sp.  gr.  0*720,  mixed 
with  an  f  qual  part  of  hydride  of  amyl  (Rhigolene). 


METHODS    FOR    LOCAL    ANAESTHESIA.  197 

with  sufficient  rapidity  to  numb  the  part,  thus  paralys- 
ing the  terminations  of  the  sensory  nerves. 

The  anaesthesia  is  confined  to  the  skin  and  is  very 
transient.  Recovery  of  sensation  when  the  spray 
ceases  to  work,  is  often  accompanied  with  very  painful 
smarting  and  tingling.  The  great  drawback  of  the 
method  is  that  the  instruments  and  skin  get  thickly 
coated  with  ice  which  obscures  the  parts,  rendering  the 
use  of  the  knife  almost  impossible.  Further,  under 
ether  spray  it  is  difficult  to  see  and  secure  blood-vessels, 
and  painful  to  do  this  when  the  anaesthesia  has  passed 
off.  Unless  care  be  taken,  the  skin  may  be  so  much 
frozen  that  a  slough  like  that  of  frost-bite  will  follow. 

Chloride  of  Methyl  (CH3C1).— Another  method 
of  rendering  tissue  insensitive  by  refrigeration  is  that 
obtained  by  allowing  the  liquid  chloride  of  methyl  to 
drop  upon  the  skin  or  mucous  membrane.  It  possesses 
a  boiling  point  of  —  23 3  C,  is  capable  of  being  kept  in 
the  liquid  state  in  metal  bottles  under  a  high  pressure. 
There  is  some  slight  danger  in  using  it,  namely,  that 
unless  the  action  is  kept  carefully  under  control,  and 
this  is  not  easy,  there  may  be  severe  injury  to  the 
vitality  of  the  tissue  subjected  to  its  influence. 

Alcohol  has  been  used  to  produce  local  anaesthesia. 
It  possesses  the  property  of  removing  sensation  to  pain, 
while  tactile  sense  persists.  Alcohol  is  cooled  by 
placing  it  in  ice  and  salt,  to  ten  degrees  or  so,  below 
freezing  point,  and  the  part  to  be  numbed  is  then 
placed  in  it.  The  use  of  alcohol  for  anaesthetic  pur- 
poses is  not  advisable  except  as  a  make- shift. 

Carbolic  acid  painted  over  the  skin  possesses  some 
benumbing  power,  but  its  effect  does  not  penetrate  at  all 
deeply,  and  is  disadvantageous  inasmuch  as  the  tissue 
touched  is  damaged  by  the  caustic  action  of  the  acid. 


198  ANESTHETICS. 

Faradic  currents  directed  for  some  minutes  through 
an  area  of  skin  or  mucous  membrane,  are  held  by  a  few 
to  produce  anaesthesia.  At  one  time  this  method  was 
in  vogue  among  dentists ;  it  has  now  fallen  into  disuse. 
A  recent  attempt  has  been  made  to  revive  this  plan,  an 
improved  apparatus  being  employed,  but  the  success 
achieved  seems  to  have  been  so  slight  as  to  make  it 
hardly  necessary  to  particularise  its  features. 

Rhigolene,  a  product  of  the  distillation  of  petroleum, 
was  introduced  by  Richardson,  who  employed  it  instead 
of  ether  in  his  atomising  spray.  Rhigolene  has  a 
sp.  gr.  of  '625  ;  it  is  one  of  the  most  volatile  substances 
known,  and  so  needs  to  be  kept  in  strong,  well-stop- 
pered bottles. 

The  uses  and  precautions  described  under  the  head, 
"local  anaesthesia — Ether  "  apply  to  rhigolene. 

Bisulphide  of  carbon,  although  an  effectual  local 
anaesthetic,  when  used  from  a  spray  or  by  irrigation, 
possesses  the  insuperable  disadvantages  of  having  a  dis- 
gusting odour  and  of  being  a  potent  poison. 


MEDICO-LEGAL    ASPECTS.  190 


CHAPTER   XII. 

Medico-Legal     Aspects    of    the     Administeation     of 
Anaesthetics. 

The  administration  of  an  anaesthetic  to  a  patient  who 
is  not  a  minor,  against  his  will,  constitutes  an  assault. 
When  a  patient  has  voluntarily  submitted  himself  to  be 
anaesthetised,  he  may,  under  the  influence  of  terror,  dur- 
ing an  early  stage  of  the  proceedings  attempt  to  pre- 
vent further  narcosis  ;  he  is  then  not  sufficiently  guided 
by  his  reason,  and  the  administrator  is  bound  in  the 
patient's  interest  to  take  his  own  course. 

The  anaesthetist,  like  any  other  medical  man,  is  liable 
to  prosecution  for  malpraxis ;  it  then  rests  with  him  to 
prove  that  whatever  steps  he  took  were  adopted  after 
due  consideration  and  because  he  believed  them  to  be 
the  best  he  could  follow  for  the  benefit  of  his  patient. 
Such  questions  as  the  following  might  arise : — Did  the 
anaesthetist  undertake  a  duty  which  knowledge,  skill, 
and  experience  had  qualified  him  to  fulfil '?  Did  he 
employ  the  most  suitable  agent  according  to  his  view  of 
the  exigencies  of  the  case  ?  and  did  he  administer  it 
with  due  skill  and  after  the  most  approved  method  ? 
Did  he  possess  himself  of  all  necessary  facts  with 
regard  to  the  patient's  bodily  condition  ?  and  did  he 
make  due  allowance  for  these  in  the  treatment  which 
he  pursued  ?  And,  in  the  event  of  an  accident  of  any 
kind,  did  he  adopt  the  right  and  appropriate  treatment 


200  ANAESTHETICS. 

indicated  in  such  an  emergency  ?    and  was  this  done 
with  due  promptitude  ? 

Anaesthetics  have  been  employed  to  assist  in  the  per- 
petration of  various  crimes  upon  the  person  narcotised. 
Thus,  an  anaesthetic  may  he  given,  it  is  alleged,  with- 
out the  consent  of  a  person ;  or  when  given  with  his  or 
her  consent  to  effect  a  lawful  procedure,  advantage 
may  be  taken  of  the  anaesthetised  person's  helpless  con- 
dition to  perpetrate  a  crime. 

Can  an  anaesthetic  be  administered  without  consent  ? 

Firstly,  can  this  be  done  whilst  a  person  is  awake 
and  in  full  possession  of  his  senses  ?  Formerly  many 
cases  came  into  the  law  courts  in  which  the  complain- 
ant alleged  that  a  handkerchief  saturated  with  chloro- 
form was  waved  before  his  face  and  unconsciousness 
followed  immediately.  This  we  now  know  to  be  an 
impossibility  ;  a  period  of  time  varying  from  two  to 
twelve  or  more  minutes  must  elapse  before  an  indivi- 
dual succumbs  to  chloroform,  and  during  this  time 
fresh  supplies  of  the  anaesthetic  would  be  needed. 
Further,  chloroform  in  most  cases  produces  so  much 
excitement,  that  one  person  would  find  it  a  difficult 
matter  to  keep  the  victim  sufficiently  still  to  complete 
the  anaesthesia,  and  would  hardly  do  so  without  much 
noise  and  disarrangement  of  the  victim's  clothing. 
Further,  unless  food  is  avoided  before  the  anaesthetic 
is  given,  vomiting  is  very  liable  to  occur,  and  with  it  a 
return  to  consciousness. 

It  is  often  alleged  by  the  supposed  victim  that  he,  or 
she,  was  conscious  of  what  was  transpiring,  but  was 
powerless  alike  to  speak  or  resist.  Such  statements 
must  be  received  with  the  utmost  caution.  It  is  true 
that  Pean  records  cases  in  which  patients,  though  ren- 


MEDICO-LEGAL    ASPECTS. 


201 


dered  analgesic  by  ether,  retained  their  consciousness 
as  to  what  was  in  course  of  proceeding.  Cases  like 
Pean's  must  be  so  exceptional  that  one  is  tempted  to 
believe  the  anaesthetic  was  administered  very  imper- 
fectly, and  that  faith  in  the  assurance  of  the  surgeon  did 
the  rest.  Snow  also  admits  the  possibility  of  persons 
imperfectly  chloroformed  being  conscious  and  yet 
powerless  to  resist.  In  attempts  at  criminal  violence 
under  an  anaesthetic  administered  without  the  victim's 
consent — fear,  excitement,  and  struggles,  would  all  be 
against  the  possibility  of  arriving  at  loss  of  voluntary 
power  without  deep  narcosis.  It  is  very  doubtful 
whether  a  person,  be  he  an  expert  or  not,  could  nar- 
cotise a  waking  adult  against  his  will  unless  there 
existed  a  very  unusual  disproportion  between  the 
strength  of  the  two  individuals.  In  the  case  of  E.  v. 
Snarey,  the  prosecutrix  alleged  that  she  had  been  ren- 
dered insensible  instantly  by  something  being  held 
over  her  face  upon  an  handkerchief,  and  that  in  that 
condition  she  had  been  violated.  This  contention 
could  not  in  a  present  state  of  knowledge  be  admitted 
by  experts.  However,  in  a  parallel  case,  that  of  White 
v.  Howarth,  the  prosecutrix  made  a  similar  assertion, 
and  added  that  she  was  aware  of  what  was  going  on 
but  was  unable  to  resist. 

Although  the  time  required  to  thoroughly  anaesthetise 
a  patient  is  longer  when  chloroform  is  used,  than  when 
ether  is  employed,  yet,  from  the  highly  irritating  nature 
of  ether  vapour  it  is  less  easy  to  administer  to  an  un- 
willing patient  than  chloroform.  And  further,  it 
requires  the  use  of  some  apparatus  entirely  excluding 
air,  and  is  hence  less  easy  to  manipulate  by  non- 
experts.    In  general  it  may  be  affirmed,  that  if  chloro- 


202  ANESTHETICS. 

form  can  only  be  used  for  criminal  purposes  with 
difficulty,  with  ether  such  attempts  would  prove  still 
less  easy. 


Can  a  Peeson  be  Anaesthetised  duking  Sleep  '? 

Dolbeau  made  careful  experiments  with  reference  to 
this  subject,  and  his  conclusions  are  certainly  consonant 
with  the  experience  of  most  skilled  anaesthetists. 

He  first  attempted  to  anaesthetise  four  persons  during 
sleep.  Three  were  awakened  in  the  process.  In  his 
second  series  of  cases  four  persons  out  of  six  awakened, 
and  in  his  third  series  only  three  persons  awakened  out 
of  nine  to  whom  he  administered  chloroform  while 
sleeping.  Dr.  Turnbull  asserts  that  either  chloroform 
or  ether  may  be  given  during  sleep  without  awakening 
the  subject  of  the  experiment.  I  have  no  doubt  that 
chloroform  may  in  many  cases  be  so  administered,  but 
am  less  sure  about  ether  ;  in  either  case  certain  condi- 
tions must  be  present  to  ensure  success.  Only  the 
greatest  care,  skill,  and  familiarity  with  the  anaesthetic 
used  would  suffice,  and  then  we  must  predicate  the 
subject  to  be  a  sound  sleeper.  But  it  is  highly  im- 
probable that  a  novice  in  anaesthetics  would  succeed  in 
such  an  attempt. 

A  further  question  arises,  upon  which  evidence  may 
be  sought,  and  that  is  whether  in  the  event  of  his  es- 
caping capture,  it  is  possible  to  prove  the  person  at- 
tempting to  administer  an  anaesthetic  with  criminal  in- 
tent was  one  skilled  in  its  use.  To  determine  this 
offers  some  difficulties.  The  presence  of  apparatus, 
the  method  in  which  lint  or  a  handkerchief  is   folded, 


ATTEMPTED    RAPE    UNDER    ANAESTHETICS.  203 

or  blistering  of  the  lips  and  nose  from  allowing  the 
chloroform  to  drop  upon  the  face,  may  offer  a  clue.  If 
ether  be  employed  we  may  be  sure  that  the  person 
using  it  possessed  some  knowledge,  and  had  resort  to 
an  apparatus,  since  ether  given  by  the  open  method 
seldom  if  ever  carries  the  patient  beyond  a  stage  of 
delirious  excitement  producing  bellicose  struggles  such 
as  would  effectually  prevent  the  accomplishment  of 
any  criminal  design. 

Anaesthetics  have  been  given  to  assist  in  the  com- 
mittal of  robbery,  rape  and  mutilation.  What  has 
been  said  above  leaves  little  to  add  with  regard  to 
robbery. 

Attempted  Kape  under  Anesthetics. 

Many  cases  have  now  been  reported  in  which  the 
prosecutrix  has  affirmed  that  a  dentist  or  surgeon  has 
violated  her  person  while  she  was  under  the  influence  of 
an  anaesthetic.  So  frequent  are  such  charges  that  the 
greatest  care  should  be  taken  on  the  part  of  an  opera- 
tor in  order  to  ensure  the  presence  of  a  third  person,  at 
least  within  ear-shot,  and  preferably  within  sight  of  the 
administration.  No  administrator  of  an  anaesthetic  is 
safe  from  having  such  a  charge  preferred  against  him, 
and  if  he  and  his  supposed  victim  are  alone,  it  is  simply 
a  case  of  word  against  word.  Further,  the  woman  may 
be  enceinte  at  the  time  of  the  alleged  rape,  and  may 
subsequently  give  birth  to  an  infant  whose  parentage 
she  may  find  it  convenient  to  fasten  upon  the  medical 
man. 

But  it  is  not  only  designing  bad  women  who  bring 
such  charges.      Modest,  virtuous,  and  refined  gentle- 


204  ANESTHETICS. 

women  have  been  prosecutrices  in  these  cases.      The 
cause  for  this  remarkable  and  deplorable  state  of  things 
is   fortunately   not   far   to    seek.       Chloroform,    ether, 
nitrous  oxide  gas,  cocaine,  and  possibly  also  the  other 
carbon  compounds  employed  in  producing  anaesthesia, 
j)Ossess  the  property  of  exciting  sexual  emotions,  and  in 
many  cases  produce  erotic  hallucinations.      It  is  un- 
doubted  that  in   certain    persons    sexual  orgasm  may 
occur  during  the  induction   of  anaesthesia.       Women, 
especially  when  suffering  from  ovarian  or  uterine  irrita- 
tion, are  prone  to  such  hallucination,  and  it  is   almost 
impossible  to  convince  them  after  their  recovery  to  con- 
sciousness that  the  subjective  sexual  sensation  is  not  of 
objective  existence.     It  is   stated   that  women  at  their 
menstrual  periods  are  more  prone  to   erotic  hallucina- 
tions than  at  other  times,  a  fact  which  may  be  borne  in 
mind.      A  case  cited  by  Dr.  Kichardson  will  illustrate 
this  statement.     A  young  lady  had  chloroform  adminis- 
tered to  her  by  the  doctor  in  the  presence   of  a  dentist 
and  of  the  young  lady's  mother  and  father.      After  the 
tooth  had  been  extracted,  and  the  patient  became  con- 
scious,   she    steadfastly   affirmed    that    she    had    been 
criminally  assaulted  by  the  dentist,  and  to  this  state- 
ment she  adhered  although  the  four  persons  present 
in  the  room  strove  to  disabuse  her  mind. 

In  considering  the  evidence  in  such  cases,  the  follow- 
ing points  need  especial  attention  : — 

Nature  of  the  anasthetic. — Chloroform,  ether,  and  the 
other  members  of  the  carbon  anaesthetic  series,  cer- 
tainly render  persons  wholly  unable  to  protect  them- 
selves from  any  personal  ill-usage.  The  body  of  the 
anaesthetised  patient  is,  however,  rendered  utterly  flaccid, 
and  is  a  dead  weight.     If  then  there  is  any  question  of 


DEATH    UNDER    AN    ANAESTHETIC.  205 

moving  the  body,  as  for  example,  from  a  dental  chair, 
and  again  back  into  the  chair,  it  must  be  remembered 
that  such  an  undertaking  would  be  exceedingly  diffi- 
cult for  one  individual  however  strong,  and  could 
hardly  be  accomplished  without  causing  much  disar- 
rangement of  clothing. 

On  the  other  hand,  if  the  offence  was  alleged  to 
have  been  committed  when  the  patient  was  under  the 
influence  of  nitrous  oxide  gas,  it  would  have  to  be  borne 
in  mind  that  the  effect  of  this  gas  is  to  produce  first 
muscular  rigidity  and  subsequently  violent  jactitation. 
Further,  unconsciousness  only  persists  for  about  half 
a  minute,  or  in  exceptional  cases  a  trifle  longer,  and 
the  patient  regains  her  senses  with  control  over  her 
muscles  all  at  once.  This  being  so  it  is  exceedingly 
improbable  that  even  a  premeditated  and  skilfully 
planned  attempt  at  violation  would  be  successful  if  made 
under  nitrous  oxide  gas. 

A  caution  is  needed  about  admitting  the  evidence  of 
a  person  only  just  recovered  from  an  anaesthetic.  The 
following  case  illustrates  this: — A  dentist  appealed  to  a 
friend  to  extract  a  tooth.  Under  gas  he  struggled  so 
violently  that  the  operation  was  not  performed,  but  as 
he  came  to,  he  reproached  his  friend  most  bitterly, 
telling  him  he  had  felt  the  whole  pain  of  the  extraction 
and  was  even  then  suffering  torture. 

Death  under  an  Anaesthetic. 

It  becomes  requisite  to  decide  whether  the  death  was 
suicidal,  accidental,  or  due  to  an  anaesthetic  given  by  a 
second  person,  and  then  whether  that  individual  was 
an  expert  or  not.     Persons  frequently  employ  chloro- 


206  ANESTHETICS. 

form  as  an  anodyne,  and  many  deaths  have  resulted 
from  the  stopper  coming  out  of  the  bottle,  the  contents 
escaping  upon  the  patient's  pillow.  The  presence  of  a 
phial  near  the  corpse  might  point  to  self-administra- 
tion. Ether  is  not  used  similarly,  and  is  not  selected 
by  suicides.  One  death  from  nitrous  oxide  gas  is  re- 
corded from  America.  A  dentist  whilst  under  the  in- 
fluence of  drink,  placed  himself  in  his  chair  and  turn- 
ing on  the  gas  held  the  face-piece  over  his  mouth  and 
nose.  In  the  morning  he  was  found  dead  and  the 
gasometer  empty. 

It  is  important  to  carefully  search  for  evidence  as  to 
how  the  anaesthetic  was  administered,  as  this  may 
determine  whether  it  was  done  secundum  artem  or 
unskilfully. 

The  enquiry  into  a  death  supposed  to  be  from  an 
anaesthetic  commences  with  the  question — was  it  due 
to  the  narcotic,  or  to  haemorrhage,  shock,  exhaustion, 
or  some  other  mischance  following  surgical  interfer- 
ence. The  mode  of  death  due  to  chloroform,  ether,  and 
other  agents  is  described  under  the  heading  chloroform, 

&G. 

The  choice  of  the  anesthetic  would  have  to  be  justi- 
fied ;  thus  were  chloroform  given  for  a  simple  tooth 
extraction  in  lieu  of  the  safer  agent  nitrous  oxide  gas, 
and  were  the  patient  to  succumb,  the  administrator 
could  with  reason  be  severely  censured  for  subjecting 
his  patient  to  such  an  unnecessary  danger. 

All  anaesthetics  are  dangerous.  In  the  hands  of  one 
skilled  in  their  use  this  danger  is  minimised  ;  but  what- 
ever may  be  individual  uses  and  opinions,  the  general 
consensus  of  belief  places  anaesthetics  in  the  following 
order  of  safety  : — nitrous  oxide  gas  when  used  for  short 


TABLE     SHOWING    DEATH-EATE. 


207 


operations  ;  ether  ;  chloroform.  Other  substances  are 
not  used  sufficiently  often  to  make  statistics  reliable, 
but  the  following  table  gives  a  rough  estimate  of  their 
danger.* 


Table  Showing  Death- bate  under  the  Various  Anaes- 
thetic Bodies. 


Chloroform  (Coles,  Virginia) 
,,  (Eichardson)    ... 

,,         Baudens  (during  Crimean 

War)     

,,         War  of  Secession 
,,         Lawrie  (Hyderabad) 
,,         Juilliard  (Geneva)     . 

Ether  (Andrews)  f       

„     Juilliard  (Geneva)    ... 

,,     Lee  (Chicago) 

Nitrous  oxide  gas       

Amylene0 

Hydrobromic  ether0 

A.C.E.  Mixture,  No.  not  ascertainable^ 

Methylene  mixture     1 

It  must  be  added  that  Scotland  presents  a  series  of 
statistics  much  more  favourable  to  chloroform ;  thus 
out  of  36,500  administrations  at  the  Edinburgh  Infir- 

*  No  great  stress  can  be  laid  upon  sucb  figures,  as  in  many  cases  a 
death  occurred  very  early  in  the  career  of  an  anaesthetic,  and  this 
rendered  further  trials  of  it  inadvisable. 

f  Probably  too  low  an  estimate. 

X  Eichardson  states  erroneously  that  no  death  has  occurred  under 
A.C.E.  mixture.     Dr.  Eeeve,  of  Dayton,  Ohio,  reports  3  deaths. 


Deaths. 

Administrations. 

53 

152,260 

1 

2500  to  3000 

in 
1 

10,000 

1 

11,448 

0 

45,000 

161 

524,507 

1 

23,204 

1 

14,987 

4 

92,816 

1 

100,100 

2 

238 

2 

(?) 

5000 


208  ANESTHETICS. 

mary  during  ten  years,  only  one  death  has  been  re- 
corded. Inquiries  recently  made  have  revealed  that 
several  deaths  from  chloroform  have  occurred  at  the 
various  surgical  centres  of  Scotland,  so  that  the  above 
estimate  can  no  longer  be  taken  as  a  reliable  statement 
of  the  death-rate  from  chloroform. 

Dr.  McEwen  gives  his  own  results  at  Glasgow  (com- 
puted, not  recorded)  as  11,886  cases  of  anesthetics, 
500  of  which  were  ether  cases.  He  makes  various 
deductions  from  his  total  and  regards  10,000  with  one 
death  as  his  chloroform  record.  Sir  George  Macleod 
mentions  15,000  cases  with  one  death,  and  Dr. 
Buchanan  9,000  with  one  death.  This  gives  the  total 
of  34,000  with  3  deaths,  or  1  in  11,000  about,  for  three 
leading  Scotch  surgeons. 

Questions  of  responsibility  when  the  patient  dies 
under  an  anesthetic  may  involve  those  as  to  whether 
the  most  suitable  anesthetic  was  given  him.  Some- 
times a  patient  refuses  one  anesthetic,  preferring 
another ;  here  the  administrator  clearly  cannot  shirk 
responsibility,  but  must  give  that  agent  which  he  deems 
best,  without  regard  to  the  whim  of  the  patient.  In 
the  converse  case,  when  death  occurs  during  the  admin- 
istration of  an  anesthetic  which  the  patient  declined  to 
take  until  persuaded,  cajoled,  or  cheated  into  so  doing, 
the  anesthetist  would  have  to  show  that  his  special 
knowledge  guided  him  in  making  his  selection,  which 
although  it  led  to  a  fatal  result,  was  in  point  of  fact,  the 
best  he  could  do  for  the  patient.  In  the  employment  of 
a  new  or  untried  anesthetic,  very  grave  responsibility 
would  rest  with  the  administrator  unless  he  very  fully 
and  clearly  explained  the  possible  results,  and  obtained 
the  patient's  consent  to  the  experiment. 


MEDICO-LEGAL    ASPECTS.  209 

A  question  which  we  have  not  yet  considered  arises — 
who  in  the  eye  of  the  law  is  qualified  to  administer  an 
anaesthetic  ?  At  present  some  uncertainty  exists  upon 
the  point,  owing  to  discretionary  power  being  left  to  the 
operator  to  assume  the  so-called  responsibility  of  the 
anaesthetic.  Thus  butlers,  coachmen,  dispensers,  and 
various  unqualified  persons  are  frequently  permitted 
to  give  the  anaesthetic,  or  as  the  phrase  is,  "keep  it 
going,"  while  the  surgeon  besides  operating  is  supposed 
to  exercise  a  general  supervision  over  the  administra- 
tor's proceedings.  If  any  accident  happens,  the  cer- 
tificate is  duly  signed  by  the  surgeon,  and  the  coroner's 
court  admits  the  principal's  evidence.  It  cannot  be 
doubted  that  to  give  any  individual  an  anaesthetic  sub- 
jecting him  to  a  minimum  of  danger  is  all  one  person 
can  do,  and  can  only  be  accomplished  by  those  specially 
instructed  and  experienced  in  anaesthetics. 

"Were  an  action  for  damages  raised  upon  a  death 
occurring  under  the  above  named  circumstances,  there 
is  little  doubt  that  the  persons  proceeded  against  would 
be  heavily  mulcted,  since  nothing  short  of  the  utmost 
emergency  could  justify  the  proceeding. 

Eecently  an  action  for  malpraxis  was  taken  out  in  a 
Colonial  court  against  a  medical  man  who  lost  a  patient 
whilst  he  was  administering  chloroform.  The  question 
rested  upon  whether  the  anaesthetic  was  rightly  and 
skilfully  given,  which  being  taken  as  proved,  the  court 
decided  the  case  in  favour  of  the  medical  man. 

How  far  dentists  practising  with  or  without  the 
L.D.S.  diploma  are  legally  justified  in  administering 
anaesthetics  is  a  moot  point.  Many  hold  that  the 
L.D.S.  confers  a  right  to  the  administration  of  nitrous 
oxide  gas,  but  no  other  form  of  anaesthetic.     In  the 

p 


210  MEDICO-LEGAL    ASPECTS. 

United  Kingdom  no  trial  case  has,  I  believe,  been  con- 
tested. The  ground  for  this  affirmation  that  licentiates 
in  dental  surgery  possess  such  a  right  has  no  legal 
basis,  but  has  grown  out  of  the  belief  that  the  use  of 
nitrous  oxide  gas  is  part  and  parcel  of  the  dentist's 
business,  and  that  so  he  has  a  right  to  employ  it. 
This,  however,  applies  with  equal  force  to  all  registered 
dental  practitioners.  Probably  the  issue  would  hinge, 
in  the  present  ambiguous  condition  of  the  law,  rather 
upon  the  previous  experience  and  recognised  skill  of 
the  person  administering  the  anesthetic,  than  upon 
bare  qualification.  Thus,  could  it  be  shown  that  a 
registered  practitioner,  after  two  or  three  thousand 
successful  administrations,  met  with  an  accident,  in 
spite  of  all  due  care  and  precaution,  he  would  probably 
be  in  a  better  position  than  would  a  well  qualified  prac- 
titioner, who  met  with  a  fatality  presumably  through 
mal- adroitness,  if  it  were  shown  that  he  had  never  ob- 
tained a  practical  experience  in  anaesthetising. 

In  any  case  a  person  would  be  open  to  grave  cen- 
sure, if  not  liable  for  malpraxis,  were  he  to  undertake 
the  administration  of  an  anaesthetic,  and  operate 
single-handed,  unless  it  could  be  shown  that  to  do  so 
was  a  necessity,  no  help  being  accessible. 

It  has  been  made  a  subject  of  much  debate  with 
whom  rests  the  responsibility  of  the  choice  of  the 
anaesthetic,  the  surgeon  who  operates,  or  the  anaes- 
thetist who  gives  the  chloroform  or  ether,  &c.  ? 
Clearly  this  must  depend  entirely  upon  the  under- 
standing which  exists  between  the  two.  If  the  anaes- 
thetist is  called  in  as  an  expert  to  decide  what  anaes- 
thetic is  best  for  any  given  patient,  his  must  be  the 
whole  responsibility ;  while  if  he  is  present  simply  as  an 


DEATHS    FROM    NITROUS    OXIDE    GAS.  211 

assistant  to  the  surgeon  to  give  in  the  best  possible 
way  an  anaesthetic  which  is  named  by  the  latter,  his 
responsibility  can  extend  only  so  far  as  the  actual  ad- 
ministration is  concerned.  If  the  two  disagree  the 
surgeon  insisting  upon  an  anaesthetic  which  the  anaes- 
thetist conscientiously  believes  will  jeopardise  the 
patient's  life,  the  surgeon  cannot  cover  the  anaesthetist, 
and  the  latter  has  but  one  course  to  adopt,  namely,  to 
retire  from  the  case.  As,  however,  the  experience  of 
the  surgeon  will  probably  equal  that  of  his  colleague, 
and  as  the  patient  is  his,  it  is  a  grave  step  for  any 
anaesthetist  to  adopt,  and  could  only  be  justified  in 
most  extreme  cases. 

Death  from  Nitrous  Oxide  Gas. 

The  deaths  which  have  occurred  when  the  patient 
had  inhaled  or  was  inhaling  the  gas,  cannot  be  imputed 
to  any  specific  action  it  exercised.  In  some  cases  heart 
failure  occurred  upon  the  patients,  resuming  conscious- 
ness before  the  operation  ivas  completed,  and  in  others 
respiration  was  interfered  with  by  gags  slipping  and 
setting  up  laryngeal  spasm.  In  a  recent  case  death 
occurred  in  an  elderly  lady  who  wore  extremely  tight 
corsets,  whose  heart  was  diseased  and  whose  stomach 
contained  food.  The  gas  was  also  administered  twice. 
Unquestionably  there  is  danger  if  the  patient  is  al- 
lowed to  feel  pain,  especially  in  operations  upon  the 
fifth  pair  of  nerves,  but  little  if  any  when  the  gas  is 
given  fully  and  the  operator  warned  to  desist  before 
consciousness  returns. 

The  P.M.  appearances  are    simply  those   of  death 
from  syncope,  or  death  from  asphyxia. 

p  2 


212  DEATH    FROM    ETHER. 


Death  from  Ether. 

If  viewed  before  death,  the  individual  will  be  found 
to  be  lethargic  or  comatose,  breathing  slowly,  deeply, 
and  with  stertor,  the  skin  pale  and  cold  and  covered 
with  clammy  sweat.  The  exposed  mucous  membranes 
will  be  purplish ;  the  face  livid  ;  the  pulse  quick,  soft, 
small,  and  compressible.  Complete  muscular  relaxa- 
tion gives  the  body  a  flaccid  doughy  feel.  The  eye  is 
fixed  and  glassy,  and  usually  smeared  with  a  thick  film 
of  mucus,  the  pupil  is  dilated  and  insensitive  to  light. 
The  body  temperature  is  depressed  several  degrees 
below  normal. 

If  the  vapour  has  been  inhaled,  a  much  smaller  dose 
is  needed  than  when  ether  is  swallowed.  The  effects 
given  above  may  be  brought  on  in  from  three  to  five 
minutes.  Six  drachms  to  an  ounce  are  necessary  to 
produce  narcotism  when  swallowed. 

Post-mortem  appearances. — If  examined  within 
twenty- four  hours  after  death,  the  brain,  lungs,  liver, 
spleen  or  kidneys,  upon  being  cut  give  a  strong  ethereal 
smell.  The  blood  is  dark  and  thick,  although  still 
fluid.  The  lungs  are  congested  posteriorly  and  filled 
with  aerated  spumous  fluid  in  front  (Taylor).  The 
bronchial  mucous  membrane  is  reddened  from  injection 
throughout  its  entire  extent.  The  cerebral  and  spinal 
vessels  are  found  congested,  and  the  meninges  stained. 

Ether  when  swallowed  has  not  caused  death  in  the 
human  subject  (Taylor).  Orfila,  experimenting  upon 
dogs,  found  the  mucous  membrane  of  the  stomach  of 
a  blacky-red  colour,  acutely  inflamed  by  a  lethal  dose 
of  ether. 


DEATH    FROM    CHLOROFORM.  213 

The  duodenum  was  also  red  and  inflamed,  the  heart 
contained  black  blood  which  was  partly  coagulated. 

The  detection  of  ether  by  analysis. — Ether  in 
liquid  is  distilled  from  the  stomach  contents  and  led 
through  a  glass  tube  containing  asbestos  moistened  by 
a  mixture  of  sulphuric  acid  and  saturated  solution  of 
bichromate  of  potash.     The  asbestos  turns  green. 

Its  odour  is  also  characteristic  ;  ether  burns  with  a 
smoky  yellow  flame;  it  is  only  slightly  soluble  in  water. 

The  tissues.  —In  recent  examinations  the  odour  is 
characteristic.  Since  but  little  ether  is  absorbed  by  the 
blood,  and  of  this  little  some  is  converted  into  aldehyde 
(Taylor),  it  is  almost  impossible  to  separate  ether  from 
it  or  the  solid  tissues  by  distillation. 


Death  from  Poisoning  by  Chloroform 

May  occur  through  inhaling  the  vapour  or  drinking 
the  fluid.  If  examined  before  death  the  individual  will 
be  comatose,  breathing  stertorously  with  slow,  shallow 
respirations.  The  skin  will  be  cold  and  blanched,  the 
face  livid,  the  lips  ashen  in  hue,  the  pulse  imperceptible, 
and  the  pupils  may  be  widely  dilated,  but  insensitive  to 
light.  Muscular  flaccidity  is  present,  but  epileptiform 
convulsions  often  occur. 

Post-mortem  appearances. — In  cases  of  death 
from  chloroform  the  appearances  reported  vary  veiy 
much,  and  this  is  probably  due  to  the  confusion  present 
in  the  minds  of  many  persons  concerning  the  con- 
nexion of  cause  and  effect.  Thus  death  from  asphyxia, 
fear,  shock,  and  so  on,  are  attributed  to  chloroform  ; 
and  further,  the  autopsies  are  seldom  made  soon  enough 


214  DEATH    FROM    CHLOROFORM. 

to  be  of  any  value,  while  sufficient  note  is  seldom  taken 
of  the  stage  in  which  death  occurred.  We  should  ex- 
pect the  cadaveric  appearances  presented  in  the  first 
stage  to  differ  widely  from  those  found  in  the  last  stage, 
and  yet  in  but  few  records  have  I  been  able  to  find  any 
information  bearing  directly  upon  this  point. 

In  the  earlier  stage  chloroform  congests  the  vessels 
of  the  brain  and  cord,  and  so  this  condition,  although 
inconstant,  is  sometimes  found. 

The  lungs  are  usually  deeply  congested,  the  heart 
empty,  flaccid,  or  containing  a  little  fluid  blood.  In 
some  cases  the  right  heart  is  full,  even  to  distension,  of 
dark  fluid  blood  (asphyxia) .  The  blood  remains  fluid, 
it  is  very  dark  and  is  said  occasionally  to  contain  bub- 
bles of  gas  (Taylor).  Snow,  analysing  thirty-four  cases, 
describes  visceral  engorgement,  but  in  some  instances 
he  found  the  lungs  normal.  Casper  denies  that  any  of 
the  features  pictured  above  are  pathognomonic  of 
chloroform  poisoning.  When  the  drug  is  swallowed  it 
produces  gastro-enteritis,  and  pathological  appearances 
resulting  from  this  would  be  seen  post-mortem. 

Detection  of  chloroform. — The  odour  very  soon 
passes  off.  Dr.  Taylor  failed  to  detect  any  in  the 
blood  half  an  hour  after  administration.  Analysis  of 
the  blood  also  fails  to  reveal  any  evidence  after  half 
an  hour. 

Analysis  of  the  tissues.— The  substance  sup- 
posed to  contain  chloroform  is  placed  in  a  flask,  one  end 
of  which  is  in  a  hot-water  bath,  the  other  communi- 
cating with  a  tubulure  which  is  heated  by  a  flame. 
The  bath  is  raised  to  160°  while  the  tube  is  heated  to 
redness.  Chloroform  vapour  driven  off  by  the  heat  of 
the   water   bath  is  split  up  as  it  traverses  the  tube, 


SELF-INDULGENCE    IN    ANAESTHETICS.  215 

chlorine  and  hydrochloric  acid  being  set  free.  The 
vapour  reddens  blue  litmus,  precipitates  solutions  of 
nitrate  of  silver,  and  liberates  iodine  from  iodide  of 
potassium  which  is  tested  in  the  usual  way  with  starch 
paper. 

Self-Indulgence  in  Anesthetics. 

A  "habit"  has  been  unhappily  created  for  most 
forms  of  anaesthetics.  Thus,  some  persons  become  ad- 
dicted to  self- administration  of  chloroform  ;  others  to 
that  of  ether ;  others  again  to  that  of  chloral ;  while 
cocaine  also  has  its  victims.  It  is  not  within  the  scope 
of  the  present  work  to  describe  the  proper  modes  of 
treating  the  slaves  of  such  unfortunate  habits,  but 
merely  to  draw  attention  to  them,  that  medico-legal 
questions  arising  out  of  such  depraved  practices  may 
receive  due  notice.  Nitrous  oxide  gas,  although  pre- 
senting greater  difficulties  to  self- administration,  has 
yet  led  some  weakly  principled  persons  to  practise  self- 
induction  of  anaesthesia  by  its  aid. 

The  possibility  of  the  subject  of  an  inquiry — in  cases 
of  supposed  suicide  or  murder  by  anaesthetics — being  an 
habitue  of  one  of  them,  should  not  be  allowed  to  drop 
out  of  mind. 

Insanity  following  the  Administration  of 
Anesthetics. 

Among  persons  predisposed  to  insanity  the  adminis- 
tration of  anaesthetics  may,  in  certain  rare  cases,  deter- 
mine an  attack  of  mania.  "It  is  the  fact  of  the 
temporary  disturbance  of  function,  and  not  the  means 
by  which  this  is  produced,  which  is  of  most  impor- 


216  INSANITY    FOLLOWING    ANESTHETICS. 

tance  "  (Savage).  It  is  stated  upon  the  high  authority 
of  Dr.  Savage  that  chloroform,  ether,  nitrous  oxide  gas, 
and  indeed  any  anaesthetic,  is  capable  of  so  interfering 
with  brain  functions,  that  the  delirium  of  commencing 
narcosis  may  become  reproduced  upon  the  patient's 
recovering  from  the  sway  of  the  anaesthetic,  and  may 
either  persist  as  intractable  mania  or  pass  off  after  ex- 
pending its  violence  in  a  sharp  but  transient  maniacal 
seizure.  This  liability  was  also  noted  in  1865  by 
various  speakers  at  the  meeting  of  the  Superintendents 
of  American  Institutions  for  the  Insane,  at  least  as  far 
as  chloroform  and  ether  were  concerned.  The  possi- 
bility of  such  a  result  ensuing  upon  the  administration 
of  an  anaesthetic  to  a  person  either  highly  neurotic  or 
coming  from  a  family  in  which  insanity  has  been 
developed,  should  be  borne  in  mind  when  such  indivi- 
duals are  examined  with  a  view  to  ascertain  their  fitness 
for  anaesthetisation. 


INDEX. 


ABDOMINAL  surgery,  25,  169 
A.  C.  E.  mixture,  142 

administration   of,  143 
after  effects,  144 
Martindale's,  143 
Richardson's,  144 
Accidents  under  anaesthetics,  171 
Adenoids,  post-nasal,  anaesthetics,  in 

removal  of,  23,  166 
Administration  of  nitrous  oxide  gas, 
36 

amylene,  133 
chloroform,  109 
ether,  84 
ethideno,  136 
hydrobromic  ether,  138 
mixtures  (see  Chapter  VII.) 
Aged  persons,  choice  of  anaesthetics 

for,  19 
Albuminuria  after  chloroform,  130 
Alcohol  for  local  anaesthesia,  197 
Allis's  ether  inhaler,  82 
Amylene,  131 
Anaesthetics,  abuse  of,  215 
Anaesthetising  during  sleep,  202 
Apparatus,  Clover's,  for  nitrous  oxide 
gas,  42 
Bert's,  63 

Dudley  Buxton's,  39 
Hewitt's,  78 
Apoplectic  seizures,  179 
Arterial  disease,  choice  of  anaesthe- 
tics in,  19 


Artificial  respiration,  176 

Howard's  method,  177 

Silvester's  method,  176 
Asphyxia,  under  chloroform,  125 

treatment  of,  126 
Asthmatics,   choice    of    anaesthetics 

for,  18 
Astigmatism  after  chloroform,  130 


""DEBT'S,  Paul,  method  of  giving 
-*— '     nitrous  oxide  gas,  63 
Billroth's  mixture,  142,  146 
Bisulphide  of  carbon  as  a  local  anaes- 
thetic, 198 
Brain  surgery,  anaesthetics  in,  162 
Brain  tumours,    ether     contra-indi- 
cated, 70 
Braine,  Mr.,  on  supplemental  bags, 

45 
Bromide  of  ether  (see  Hydrobromic 

ether),  137 
Brucine,  195 

Buxton,   Dudley,  researches  on  ni- 
trous oxide,  33 

apparatus    for  giving  nitrous 

oxide,  39 
chloroform  inhaler,  113 
gag,  47 

mouth-props,  49 
oral  net  spoon,  51 


218 


INDEX. 


CARBOLIC  acid  for  local  anaes- 
thesia, 197 
Children,  choice  of  anaesthetic  for,  17 
Chloral     hydrate     and     chloroform 

mixed,  as  an  anaesthetic,  151 
Chloral  hydrate  and  ether  mixed,  as 

an  anaesthetic,  153 
"Chloramyl,"  150 
Chloric  ether,  as  an  anaesthetic,  10 
Chloroform,  administration  of,   109, 
116, 121 
after  effects  of,  129 
and  chloral  hydrate,  151 
and  cocaine,  153 
and  dimethylacetal,  152 
and  morphine,  147 
and  tui'pentine,  152 
chemistry  of,  9-1 
chloral  and  morphine,  152 
dangers  under,  122 
death  from,  213 
detection  of,   in  tissues,  214 
discovery  of,  94 
impurities  in,  96 
inhalers,  Clover's,  109 
Dudley  Buxton's,  113 
Junker's,  112 
Sansom's,  111 
Snow's,  111 
physiological  action  of,  97 
post-mortem  appearances,  213 
preparation  of,  94 
recommended  by  Simpson,  10 
tests  for,  96 
pimple  inhaler,  115 
with  atropine  and  mor- 
phine, 148 
with  nitrite  of  amyl,  150 
Choice  of  anaesthetic  in  general  Bur- 

gory,  16 
Clover's  gas  and  ether  inhaler,  41 
c  hlo  roform  inhaler,  109 


Clover's  ether  inhaler,  74 

(modified  by  Hewitt),  78 
addition  to,  by  Dr.  Shepherd, 
77 
Cocaine,  180 

accidents  from,  193 

after  effects  of,  193 

and  chloroform,  153 

Coming's  method  of  using,  188 

iu  dental  surgery,  192 

in  major  operations,  193 

in  operations     on     larynx    and 

pharynx,  191 
in  ophthalmic  practice,  190 
methods  of  employment-,  187 
physical  properties,  180 
physiological  action  of,  182 
treatment    of   accidents  under, 

194 
salts  of,  181 
when  to  be  used,  190 
Consciousness  under  anaesthetics,  200 
Craniotomy,  anaesthetics  for,  16L 
Crimes,  commission  of,  under  anaes- 
thetics, 200 


~pvEATH  under  anaesthetics,  205 
•*—'     Dental   surgery,   anaesthetics 

in,  37,  107 
Dentists,  can  they  legally  give  anaes- 
thetics ?  2U9 
Diet,  before  and  after  anaesthetics,  15 
Dimethylacetal  and  chloroform,  152 
Drumine,  195 


ELECTRICITY   (see  Faradism), 
198 
Emphysematous  persons,    anaesthe- 
tics for,  18 


INDEX. 


219 


Empyema,  choice  of  anaesthetics  for, 

163 
Epilepsy,   treatment    of    fits    under 

chloroform,  179 
Ether,  accidents  under,  88 
after  effects,  91 

and  chloral  mixed,  as  an  anaes- 
thetic, 153 
and     morphine    mixed,    as     an 

anaesthetic,  149 
and  nitrous  oxide,  41,  154 
by  the  rectum,  86 
chemistry  of,  67 
coughing  caused  by,  90 
dangers  of,  88 
death  from,  212 
detection  of,  in  tissues,  213 
discovery  of,  07 
for  infants,  70 
impurities  of,  68 
in  collapse,  91 
inhaler,  Allis's,  83 

Clover's,  74 

cone,  81 

Ormsby's,  81 

Eendle's,  84 
methods  of  administration,  73 
physiological  action,  70 
poisoning  by,  212  [212 

post-mortem  appearances  after 
respiration,  dangers  to,  88 
spray,  196 
suggested   as  an  anaesthetic  by 

Faraday,  7 
the  heart,  dangers  to,  under,  89 
treatment  of  accidents  under,  89 
used     as     an     auaesthetic     by 

Morton,  9 
vomiting  caused  by,  90 
when  inapplicable,  69 
^thidene  chloride  (dichloride),  134 
administration,  136 


Ethidene  dangers  of,  137 
Eye,  operations  on,  anaesthetics   for} 
24,  162 


FARADISM,  198 
Fontaine's,  Dr.,  nitrous  oxide 
chamber,  65 
Foreign   bodies  in   mouth,    dangers 
from  under  nitrous  oxide,  58,  171 
in  mouth,  treatment,  59,  173 
entrance   of,  into    air    passages 
under  chloroform,  127 


GAGS,  47 
General  Surgery,  nitrous  oxide 
in,  36 
Glottis,  spasm  of,  173 
Glycosuria  after  chloroform,  130 
Govvan's  gag,  48 


"]    |~EART,     disease  of,  choice   of 
-* — *-     anaesthetics  in,  20 
Hewitt's  gas  and  ether  inhaler,  79 

prop,  51 
Hiccough,  under  ether,  treatment  of, 

93 
Howard's  method  of  artificial  respi- 
ration, 177 
Hyderabad  Commission,  13 
Hydrobromic  ether,  accidents  from, 
140 
administration  of,  138 
complications  under,  140 
discovery  of,  137 
physiological   action  of,  138 
properties  of,  137 
treatment  of,  141 
when  applicable,  139 


220 


INDEX. 


Hypnotism,  4 

Hysterical  seizures  under  anaesthe- 
tics, 128,  129,  179 


INDULGENCE,  self-,  in  anaesthe- 
tics, 215 
Inhalers,  42,  75,  78,  79,  80,  81,  83, 

84,  113,115,  116 
Insanity  caused  by  anaesthetics,  215 
after  chloroform,  130 


■JAUNDICE  after  chloroform,  130 
"      Jaws,  operations  on,  anaesthe- 
tics for,  24,  69,  87,  163,  165 
Junker's  inhaler,  112 


IZ  IDNEY,  diseases   of,  choice  of 


i\. 


anaesthetics  in,  19 


Krohne  and  Sesemann's,  feather  re- 
spiration register,  115 

feather      respiration     register 
cone,  116 


LABOUR,  administration  of  anaes- 
thetics during,  159 
anaesthetics  in,  155 
reputed  objections  to  anaesthe- 
tising in,  157 
rules  for  anaesthetising  in,  156 
Laryngotomy,  175 
Larynx,  spasm  of,  175 
Linhart's  mixture,  142,  144 
Lister's,    Sir    Joseph    (the  Scotch) 

method  of  giving  chloroform,  116 
Local  a  naesthesia,  180 


~]\  JALPRAXIS  in  anaesthetising, 

Medico  legal  aspects  of  anaesthetics, 

199 
Methylene,  142,  144 

administration  of,  145 

after  effects  of,  146 

dangers  of,  146 

deaths  under,  145 

employment  of,  145 
Methods    of   employing    nitrite    of 

amyl  and  chloroform,  150 
Miller's  cocaine  atomiser,  189 
Morphine  and  chlorolorm,  147 

and  ether,  149 
Mortality  under  anaesthetics,  207 
Mouth-opener,  49 
Mouth-props  (dental),  49 
Mutilation  under  anaesthetics,  203 


NAUSEA    and    vomiting    under 
ether,  92 
Neurotic  persons,   choice   of   anaes- 
thetics for,  22 
Nitrite  of  amyl  and  chloroform,  150 
Nitrous  oxide,  administration,  36 

applied  to  anaesthesia  by  Horace 
Wells,  6 

discovery,  5 

in  general  surgery,  36 
Nitrous  oxide  gas,  after  effects,  59 

chemistry  of,  27 

dangers  of,  57 

deaths  under,  63,  211 

duration  of  narcosis  under,  55 

in  advanced  age,  61 

in  dental  surgery,  37 

in  heart  disease,  62 

in  lung  disease,  61 

in  phthisis,  61 

in  pregnancy,  60 


INDEX. 


221 


Nitrous     oxide     gas     physiological 
action  of,  30 

preparation  of,  27 

when  to  be  used,  36 
Nitrous  oxide  and  ether,  41,  154 
Nussbaum's  mixture,  147 


OBALINSKFS  method,  153 
Obstetric      operations,      after 
effects,   anaesthetics  in,  161 
anaesthetics  in,  160 
practice,  choice  of  anaes- 
thetics in,  25 
Operations,  choice  of  anaesthetic,  for 

particulars,  23,  et  seq. 
Ophthalmic  surgery  (see  Eye) 
Oral  net  spoon,  51 
Ormsby's  ether  inhaler,  81 
Oxygen   and    nitrous    oxide    mixed, 

Bert's  method,  63 
Oxygen   and    nitrous   oxide    mixed, 
Hewitt's  method,  64 


T)AKTURITION  {see  Labour) 
-*-       Pericardial  disease,   choice  of 

anaesthetic  in,  21 
Physiological  action  of  amylene,  131 
chloroform,  97 
cocaine,  182 
ether,  70 

ethidene  chloride,  135 
hydrobromic  ether,  138 
nitrous  oxide  gas,  30 
Pregnancy,  choice  of  anaesthetic  in, 

22,  25,  153 
Preparation  of  patient  for  anaesthe- 
tic, 14 
Puerperal    convulsions,    chloroform 
in,  161 


QUALIFICATION    for    adminis- 
tering anaesthetics,  209 


EAPE,  attempted  under  an  anaes- 
thetics, 203 
Rectal  surgery,  anaesthetics  for,  170 

etherisation,  86 
Rhigolene,  local  anaesthetic,  19S 
Robbery,  attempted,  during    anaes- 
thesia, 203 
Respiratory  centre,  paralysis  of,  173 
Respiration,  artificial,  176 

dangers  to  under  chloroform,  125 
disturbances  of  under  anaesthe- 
tics, 172 
treatment  of,  126 
Responsibility  in  anaesthetising,  210 


C  DIPSON,  Sir  James  Y.,  advocacy 

^-'     of  chloroform,  94 

Sansom's  inhaler,  Lll 

Self-indulgence  in  anaesthetics,  215 

Snow's  inhaler,  111 

Staphyloraphy,   anaesthetics  in,  23, 
164 

Stertor  under  nitrous  oxide  gas,  55 

Supplemental  bag  for  nitrous  oxide, 
44 
disadvantages  of,  44 

Sylvester's  method  of  artificial   re- 
spiration, 176 

Syncope  under  chloroform,  122,  17S 
treatment,  123,  178 
from  shock,  179 


222 


INDEX. 


THORAX,   operations  on,   anses- 
thetics  for,  25,  16S 
Tongue,  dangers  from,  under  chloro- 
form, 126 

excision  of,  anaesthetics  for,  164 
forceps,  53 
treatment,  126 
Tracheotomy,  1/4 

Treatment  of  accidents  during  anaes- 
thesia, 173 


Trelat's  method,  152 
Turpentine  and  chloroform,  152 

"YTASCULAR    feebleness,  nitrous 

*       oxide  gas  in,  61 
Vienna  mixture,  142,  144 
Vomiting  under  chloroform,  129 


"TTTELLER'S  gag,  50 


CATALOGUE  No.  7. 


JULY,   1892. 


A  CATALOGUE 

OF 

Books  for  Students. 

INCLUDING   THE 

?  QUIZ-COMPENDS  ? 


CONTENTS. 

PAGE 

PAGE 

New  Series  of  Manuals,  2,3,4,=; 

Anatomy, 

.      6 

Pathology,  Histology, . 

.  11 

Biology, 

.    II 

Pharmacy,     . 

.  12 

Chemistry,     . 

.     6 

Physical  Diagnosis, 

.  11 

Children's  Diseases,     . 

•     7 

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.  11 

Dentistry, 

.     3 

Practice  of  Medicine,    . 

11,  12 

Dictionaries, 

8,  16 

Prescription  Books, 

.  12 

Eye  Diseases, 

.     8 

?Quiz-Compends  ?     . 

14,  15 

Electricity,    . 

•     9 

Skin  Diseases, 

.  12 

Gynsecology, 

.  10 

Surgery  and  Bandaging, 

•  *3 

Hygiene, 

•     9 

Therapeutics, 

•     9 

Materia  Medica,  . 

•    9 

Urine  and  Urinary  Organs,     13 

Medical  Jurisprudence 

•    9 

Venereal  Diseases, 

•  J3 

Nervous  Diseases, 

.  10 

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copoeia, and  Directions  for  making  Artificial  Human 
Milk,  for  the  Artificial  Digestion  of  Milk,  etc.     Illus. 

"  The  merits  of  the  book  are  many.  Aside  from  the  praiseworthy 
work  of  the  printer  and  binder,  which  gives  us  a  print  and  page 
that  delights  the  eye,  there  is  the  added  charm  of  a  style  of  writ- 
ing that  is  not  wearisome,  that  makes  its  statements  clearly  and 
forcibly,  and  that  knows  when  to  stop  when  it  has  said  enough. 
The  insertion  of  typical  temperature  charts  certainly  enhances  the 
value  of  the  book.  It  is  rare,  too,  to  find  in  anj'  text-book  so  many 
topics  treated  of.  All  the  rarer  and  out-of-the-way  diseases  are 
given  consideration.  This  we  commend.  It  makes  the  work 
valuable." — Archives  of  Pedriatics ,  July ,  /Sqo. 

"  The  author  has  avoided  the  not  uncommon  error  of  writing  a 
book  on  general  medicine  and  labeling  it  '  Diseases  of  Children,' 
but  has  steadily  kept  in  view  the  diseases  which  seemed  to  be 
incidental  to  childhood,  or  such  points  in  disease  as  appear  to  be  so 
peculiar  to  or  pronounced  in  children  as  to  justify  insistence  upon 
them.  *  *  *  A  safe  and  reliable  guide,  and  in  many  ways 
admirably  adapted  to  the  wants  of  the  student  and  practitioner." — 
American  Journal  of  Medical  Science. 

"  Thoroughly  individual,  original  and  earnest,  the  work  evi- 
dently of  a  close  observer  and  an  independent  thinker,  this  book, 
though  small,  as  a  handbook  or  compendium  is  by  no  means  made 
up  of  bare  outlines  or  standard  facts." — The  Therapeutic  Ga- 
zette. 

"  As  it  is  said  of  some  men,  so  it  might  be  said  of  some  books, 
that  they  are  'born  to  greatness.'  This  new  volume  has,  we 
believe,  a  mission,  particularly  in  the  hands  of  the  younger 
members  of  the  profession.  In  these  days  of  prolixity  in  medical 
literature,  it  is  refreshing  to  meet  with  an  author  who  knows  both 
what  to  say  and  when  he  has  said  it.  The  work  of  Dr.  Goodhart 
(admirably  conformed,  by  Dr.  Starr,  to  meet  American  require- 
ments) is  the  nearest  approach  to  clinical  teaching  without  the 
actual  presence  of  clinical  material  that  we  have  yet  seen." — New 
York  Medical  Record. 

Prioe  of  each  Book,  Cloth,  $3.00  ;  Leather,  $3.50. 


THE   NEW  SERIES  OF  MANUALS. 


No.  6.    PRACTICAL  THERAPEUTICS. 

FOURTH  EDITION,  WITH  AN  INDEX  OF  DISEASES. 

Practical  Therapeutics,  considered  with  reference  to 
Articles  of  the  Materia  Medica.  Containing,  also,  an 
Index  of  Diseases,  with  a  list  of  the  Medicines 
applicable  as  Remedies.  By  Edward  John  Waring, 
m.d.,  f.r.c.p.  Fourth  Edition.  Rewritten  and  Re- 
vised by  Dudley  W.  Buxton,  m.d.,  Asst.  to  the  Prof, 
of  Medicine  at  University  College  Hospital. 

"  We  wish  a  copy  could  be  put  in  the  hands  of  every  Student  or 
Practitioner  in  the  country.  In  our  estimation,  it  is  the  best  book 
of  the  kind  ever  written." — N.  Y.  Medical  Journal . 

"  Dr.  Waring's  Therapeutics  has  long  been  known  as  one  of  the 
most  thorough  and  valuable  of  medical  works.  The  amount  of 
actual  intellectual  labor  it  represents  is  immense.  .  .  .  An  in- 
dex of  diseases,  with  the  remedies  appropriate  for  their  treatment, 
closes  the  volume." — Boston  Medical  and  Surgical  Reporter. 

"  The  plan  of  this  work  is  an  admirable  one,  and  one  well  calcu- 
lated to  meet  the  wants  of  busy  practitioners.  There  is  a  remark- 
able amount  of  information,  accompanied  with  judicious  comments, 
imparted  in  a  concise  yet  agreeable  style." — Medical  Record. 

No.  7.    MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

THIRD  REVISED  EDITION. 

By  John  J.  Reese,  m.d.,  Professor  of  Medical  Jurispru- 
dence and  Toxicology  in  the  University  of  Pennsyl- 
vania ;  President  of  the  Medical  Jurisprudence  Society 
of  Phila. ;    Third  Edition,  Revised  and  Enlarged. 

"This  admirable  text-book." — Amer.Jour.  of  Med.  Sciences. 

"  We  lay  this  volume  aside,  after  a  careful  perusal  of  its  pages, 
with  the  profound  impression  that  it  should  be  in  the  hands  of  every 

doctor  and  lawyer.     It  fully  meets  the  wants  of  all  students 

He  has  succeeded  in  admirably  condensing  into  a  handy  volume  all 
the  essential  points." — Cincinnati  Lancet  and  Clinic. 

"  The  book  before  us  will,  we  think,  be  found  to  answer  the  ex- 
pectations of  the  student  or  practitioner  seeking  a  manual  of  juris- 
prudence, and  the  call  for  a  second  edition  is  a  nattering  testimony 
to  the  value  of  the  author's  present  effort.  The  medical  portion 
of  this  volume  seems  to  be  uniformly  excellent,  leaving  little  for 
adverse  criticism.  The  information  on  the  subject  matter  treated 
has  been  carefully  compiled,  in  accordance  with  recent  knowledge. 
The  toxicological  portion  appears  specially  excellent.  Of  that  por- 
tion of  the  work  treating  of  the  legal  relations  of  the  practitioner 
and  medical  witness,  we  can  express  a  generally  favorable  ver- 
dict."— Physician  and  Surgeon,  Ann  Arbor,  Mich. 

Price  of  each  Book,  Cfoth,  $3,00;  Leather,  $3.50. 


6  STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

ANATOMY. 

Macalister's  Human  Anatomy.    816  Illustrations.    A  new 

Text-book  for  Students  and  Practitioners,  Systematic  and  Topo- 
graphical, including  the  Embryology,  Histology  and  Morphology 
of  Man.  With  special  reference  to  the  requirements  of 
Practical  Surgery  and  Medicine.  With  816  Illustrations, 
400  of  which  are  original.     Octavo.       Cloth,  7.50;  Leather,  8.50 

Ballou's  Veterinary  Anatomy  and  Physiology.  Illustrated. 
By  Wm.  R.  Ballou,  m.d.,  Professor  of  Equine  Anatomy  at  New 
York  College  of  Veterinary  Surgeons.  29  graphic  Illustrations. 
i2mo.  Cloth,  1.00;  Interleaved  for  notes,  1.25 

Holden's  Anatomy.  A  manual  of  Dissection  of  the  Human 
Body.  Fifth  Edition.  Enlarged,  with  Marginal  References  and 
over  200  Illustrations.     Octavo. 

Bound  in  Oilcloth,  for  the  Dissecting  Room,  $4.50. 
"  No  student  of  Anatomy  can  take  up  this  book  without  being 
pleased  and  instructed.  Its  Diagrams  are  original,  striking  and 
suggestive,  giving  more  at  a  glance  than  pages  of  text  description. 
*  *  *  The  text  matches  the  illustrations  in  directness  of  prac- 
tical application  and  clearness  of  detail." — New  York  Medical 
Record. 

Holden's  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone  and 
its  Development.  With  Lithographic  Plates  and  Numerous  Illus- 
trations.    Seventh  Edition.     8vo.  Cloth,  6.00 

Holden's  Landmarks,  Medical  and  Surgical.  4th  ed.   Go.,  1.25 
Heath's  Practical  Anatomy.    Sixth  London  Edition.    24  Col- 
ored Plates,  and  nearly  300  other  Illustrations.  Cloth,  5.00 
Potter's  Compend  of  Anatomy.     Fifth  Edition.     Enlarged. 
16  Lithographic  Plates.     117  Illustrations.    See  Page  14. 

Cloth,  1. 00;  Interleaved  for  Notes,  1.25 

CHEMISTRY. 

Bartley's  Medical  Chemistry.  Second  Edition.  A  text-book 
prepared  specially  for  Medical,  Pharmaceutical  and  Dental  Stu- 
dents. With  50  Illustrations,  Plate  of  Absorption  Spectra  and 
Glossary  of  Chemical  Terms.    Revised  and  Enlarged.    Cloth,2.so 

Trimble.  Practical  and  Analytical  Chemistry.  A  Course  in 
Chemical  Analysis,  by  Henry  Trimble,  Prof,  of  Analytical  Chem- 
istry in  the  Phila.  College  of  Pharmacy.  Illustrated.  Fourth 
Edition,  Enlarged.     8vo.  Cloth,  1.50 

Mf&~  See  Paget  2  to  j  for  list  0/ Students'  Manuals . 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.         7 

Chemistry  : — Continued. 
Bloxam's  Chemistry,  Inorganic  and  Organic,  with  Experiments. 
Seventh  Edition.     Enlarged  and   Rewritten.     281   Illustrations. 

Cloth,  4.50 ;  Leather,  5.50 

Richter's  Inorganic  Chemistry.  A  text-book  for  Students. 
Third  American,  from  Fifth  German  Edition.  Translated  by 
Prof.  Edgar  F.  Smith,  ph.d.  89  Wood  Engravings  and  Colored 
Plate  of  Spectra.  Cloth,  2.00 

Richter's  Organic  Chemistry,  or  Chemistry  of  the  Carbon 
Compounds.     Illustrated.     Second  Edition.  Cloth,  4.50 

Symonds.  Manual  of  Chemistry,  for  the  special  use  of  Medi- 
cal Students.  By  Brandreth  Symonds,  a.m.,  m.d.,  Asst. 
Physician  Roosevelt  Hospital,  Out- Patient  Department ;  Attend- 
ing Physician  Northwestern  Dispensary,  New  York.     12010. 

Cloth,  2.00 

Leffmann's  Compend  of  Chemistry.  Inorganic  and  Organic. 
Including  Urinary  Analysis.     Third  Edition.     Revised. 

Cloth,  1. 00;    Interleaved  for  Notes,  1.25 

Leffmann  and  Beam.  Progressive  Exercises  in  Practical 
Chemistry.     i2mo.     Illustrated.  Cloth,  1.00 

Muter.  Practical  and  Analytical  Chemistry.  Fourth  Edi- 
tion. Revised,  to  meet  the  requirements  of  American  Medical 
Colleges,  by  Prof.  C.  C.  Hamilton.     Illustrated.  Cloth,  2.00 

Holland.  The  Urine,  Common  Poisons,  and  Milk  Analysis, 
Chemical  and  Microscopical.  For  Laboratory  Use.  Fourth 
Edition,  Enlarged.     Illustrated.  Cloth,  1.00 

Van  Niiys.    Urine  Analysis.    Illus.  Cloth,  2.00 

■Wolff's  Applied  Medical  Chemistry.  By  Lawrence  Wolff, 
m.d.,  Dem.  of  Chemistry  in  Jefferson  Medical  College.   Clo.,  1.00 

CHILDREN. 

Goodhart  and  Starr.  The  Diseases  of  Children.  Second 
Edition.  By  J.  F.  Goodhart,  m.d.,  Physician  to  the  Evelina 
Hospital  for  Children;  Assistant  Physician  to  Guy's  Hospital, 
London.  Revised  and  Edited  by  Louis  Starr,  m.d.,  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Containing  many  Prescriptions  and  Formulae, 
conforming  to  the  U.  S.  Pharmacopoeia,  Directions  for  making 
Artificial  Human  Milk,  for  the  Artificial  Digestion  of  Milk,  etc. 
Illustrated.  Cloth,  3.00;  Leather,  3.50 

Hatfield.  Diseases  of  Children.  By  M.  P.  Hatfield,  m.d., 
Professor  of  Diseases  of  Children,  Chicago  Medical  College. 
Colored  Plate.     i2mo.  Cloth,  1.00;  Interleaved,  1.25 

See  pages  14  and  IS  for  list  of  ?  Quiz- Comp  ends? 


8  STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

Children: —  Continued. 
Starr.  Diseases  of  the  Digestive  Organs  in  Infancy  and 
Childhood.  With  chapters  on  the  Investigation  of  Disease, 
and  on  the  General  Management  of  Children.  By  Louis  Starr, 
m.d.,  Clinical  Professor  of  Diseases  of  Children  in  the  Univer- 
sity of  Pennsylvania.     Illus.    Second  Edition.  Cloth,  2.25 

DENTISTRY. 

Fillebrown.     Operative  Dentistry.    330  Illus.  Cloth,  2.50 

Flagg's  Plastics  and  Plastic  Filling.    4th  Ed.         Cloth,  4.00 
Gorgas.     Dental  Medicine.     Fourth  Edition.  Cloth,  3.50 

Harris.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery 
and  Mechanism.  Twelfth  Edition.  Revised  and  enlarged  by 
Professor  Gorgas.  1028  Illustrations.  Cloth,  7.00  ;  Leather,  8.00 
Richardson's  Mechanical  Dentistry.  Fifth  Edition.  569 
Illustrations.     8vo.  Cloth,  4.50;  Leather,  5.50 

Sewill.     Dental  Surgery.     200  Illustrations.     3d  Ed.   Clo.,  3.00 
Taft's  Operative  Dentistry.    Dental  Students  and  Practitioners. 
Fourth  Edition.     100  Illustrations.        Cloth,  4.25  ;  Leather,  5.00 
Talbot.      Irregularities   of  the   Teeth,  and  their  Treatment. 
Illustrated.     8vo.     Second  Edition.  "  Cloth,  3.00 

Tomes'  Dental  Anatomy.     Third  Ed.    "191  Illus.      Cloth,  4.00 
Tomes'  Dental   Surgery.      3d  Edition.     292  Illus.    Cloth,  5.00 
Warren.    Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    Illustrated.  Cloth,  1. 00;  Interleaved,  1.25 

DICTIONARIES. 

Gould's  New  Medical  Dictionary.  Containing  the  Definition 
and  Pronunciation  of  all  words  in  Medicine,  with  many  useful 
Tables  etc.    J^  Dark  Leather,  3.25  ;  y2  Mor.,  Thumb  Index,  4.25 

Harris'  Dictionary  of  Dentistry.  Fifth  Edition.  Completely 
revised  by  Prof.  Gorgas.  Cloth,  5.00;  Leather,  6.00 

Cleaveland's  Pronouncing  Pocket  Medical  Lexicon.  Small 
pocket  size.  Cloth,  red  edges  .75  ;  pocket-book  style,  1.00 

Longley 's  Pocket  Dictionary.  The  Student's  Medical  Lexicon, 
giving  Definition  and  Pronunciation,  with  an  Appendix  giving 
Abbreviations  used  in  Prescriptions,  Metric  Scale  of  Doses,  etc. 
241110.  Cloth,  1. 00;  pocket-book  style,  1.25 

EYE. 

Hartridge  on  Refraction.     5th  Edition.     Illus.  Cloth,  2.00 

Swanzy.     Diseases  of  the  Eye  and  their  Treatment.     158 

Illustrations.     Fourth  Edition.  Cloth,  3  00 

Fox  and   Gould.    Compend  of  Diseases  of    the   Eye  and 

Refraction.     2d  Ed.     Enlarged.     71  Illus.     39  Formulae. 

Cloth,  1. 00;  Interleaved  for  Notes,  1.25 

4&-  See  Pares  2  to  5  for  list  0/  Students'  Manuals. 


STUDENTS'  TEXT-BOOKS  AND   MANUALS.  9 

ELECTRICITY. 

Bigelow.    Plain  Talks  on  Medical  Electricity.  Cloth,  i.oo 

Mason's  Compend  of  Medical  Electricity.  Cloth,  i.oo 

Steavenson  and  Jones.     Medical  Electricity.  A  Practical 

Handbook.     Just  Ready.     Illustrated.     i2mo.  Cloth,  2.50 

HYGIENE. 

Coplin's  Practical  Hygiene.  By  W.  M.  L.  Coplin,  Adjunct 
Professor  of  Hygiene,  Jefferson  Medical  College,  Philadelphia. 
Illustrated.  In  Press. 

Parkes'  (Ed.  A.)  Practical  Hygiene.  Seventh  Edition,  en- 
larged.    Illustrated.    8vo.  Cloth,  4.50 

Parkes'  (L.  C.)  Manual  of  Hygiene  and  Public  Health. 
Second  Edition.     i2mo.  Cloth,  2.50 

Wilson's  Handbook  of  Hygiene  and  Sanitary  Science. 
Seventh  Edition.     Revised  and  Illustrated.  Cloth,  3.25 

MATERIA  MEDICA  AND  THERAPEUTICS. 

Potter's  Compend  of  Materia  Medica,  Therapeutics  and 
Prescription  Writing.  Fifth  Edition,  revised  and  improved. 
See  Page  15.  Cloth,  1.00;  Interleaved  for  Notes,  1.25 

Biddle's  Materia  Medica.  Eleventh  Edition.  By  the  late 
John  B.  Biddle,  m.d.  Revised  by  Clement  Biddle,  m.d.,  8vo, 
illustrated.  Cloth,  4.25;  Leather,  5.00 

Potter.  Handbook  of  Materia  Medica,  Pharmacy  and 
Therapeutics.  Including  Action  of  Medicines,  Special  Thera- 
peutics, Pharmacology,  etc.  By  Saml.  O.  L.  Potter,  m.d., 
m.r.c.p.  (Lond.),  Professor  of  the  Practice  of  Medicine  in 
Cooper  Medical  College,  San  Francisco.  Third  Revised  and 
Enlarged  Edition.     8vo.  Cloth,  4.00;  Leather,  5.00 

White  and  Wilcox.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  A  Handbook  for  Students. 
By  Wm.  Hale  White,  m.d.,  p.r.c.p.,  etc.,  Physician  to  and 
Lecturer  on  Materia  Medica,  Guy's  Hospital.  Revised  by 
Reynold  W.  Wilcox,  m.d.,  Professor  of  Clinical  Medicine  at  the 
New  York  Post  Graduate  Medical  School,  Assistant  Physician 
Bellevue  Hospital,  etc.     American  Edition.  In  Press. 

MEDICAL  JURISPRUDENCE. 
Reese.  A  Text-book  of  Medical  Jurisprudence  and  Toxi- 
cology. By  John  J.  Reese,  m.d.,  Professor  of  Medical  Juris- 
prudence and  Toxicology  in  the  Medical  Department  of  the 
University  of  Pennsylvania ;  President  of  the  Medical  Juris- 
prudence Society  of  Philadelphia ;  Physician  to  St.  Joseph's 
Hospital ;  Corresponding  Member  of  The  New  York  Medico- 
legal Society.       Third  Edition.  Cloth,  3.00 ;  Leather,  3.50 

£&•  See  pages  14  and  13  for  list  of  ?  Quiz- Comp  ends  f 


10        STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

NERVOUS  DISEASES. 

Gowers.  Manual  of  Diseases  of  the  Nervous  System. 
A  Complete  Text-book.  By  William  R.  Gowers,  m.d.,  Prof. 
Clinical  Medicine,  University  College,  London.  Physician  to 
National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged,  and  in  many  parts  Rewritten. 
With  many  new  Illustrations.     Octavo. 

Vol.  I.      Diseases  of  the  Nerves  and  Spinal  Cord.     616 
pages.  Cloth,  3.50 

Vol.  II.     Diseases   of  the    Brain   and  Cranial   Nerves. 
General  and  Functional  Diseases.  Nearly  Ready. 

Ormerod.  Diseases  of  Nervous  System,  Student's  Guide  to. 
By  J.  A.  Ormerod,  m.d.,  Oxon.,F.R.c.p.  (London),  Member  Path- 
ological, Clinical,  Ophthamological,  and  Neurological  Societies, 
Physician  to  National  Hospital  for  Paralyzed  and  Epileptic  and 
to  City  of  London  Hospital  for  Diseases  of  the  Chest,  Demon- 
strator of  Morbid  Anatomy,  St.  Bartholomew's  Hospital,  etc. 
With  75  Wood  Engravings.  Cloth,  2.00 

OBSTETRICS  AND  GYNECOLOGY. 

Davis.  A  Manual  of  Obstetrics.  By  Edw.  P.  Davis,  Dem- 
onstrator of  Obstetrics,  Jefferson  Medical  College,  Philadelphia. 
Colored  Plates,  and  130  other  Illustrations.     i2mo.      Cloth,  2.00 

Byford.  Diseases  of  Women.  The  Practice  of  Medicine  and 
Surgery,  zs  applied  to  the  Diseases  and  Accidents  Incident  to 
Women.  By  W.  H.  Byford,  a.m.,  m.d.,  Professor  of  Gynaecology 
in  Rush  Medical  College  and  of  Obstetrics  in  the  Woman's  Med- 
ical College,  etc.,  and  Henry  T.  Byford,  m.d.,  Surgeon  to  the 
Woman's  Hospital  of  Chicago.  Fourth  Edition.  Revised  and 
Enlarged.  306  Illustrations,  over  100  of  which  are  original. 
Octavo.     832  pages.  Cloth,  5.00;  Leather,  6.00 

Lewers'  Diseases  of  Women.  A  Practical  Text-book.  139 
Illustrations.     Second  Edition.  Cloth,  2.50 

Parvin's  Winckel's  Diseases  of  Women.  Second  Edition. 
Including  a  Section  on  Diseases  of  the  Bladder  and  Urethra. 
150  Illus.     Revised.     See  page  3.  Cloth,  3.00;  Leather,  3.50 

Morris.    Compend  of  Gynaecology.    Illustrated.      Cloth,  1.00 

Winckel's  Obstetrics.  A  Text-book  on  Midwifery,  includ- 
ing the  Diseases  of  Childbed.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology,  and  Director  of  the  Royal  University  Clinic  for 
Women,  in  Munich.  Authorized  Translation,  by  J.  Clifton 
Edgar,  m.d.,  Lecturer  on  Obstetrics,  University  Medical  Col- 
lege, New  York,  with  nearly  200  handsome  Illustrations,  the 
majority  of  which  are  original.    8vo.     Cloth,  6.00;   Leather,  7.00 

Landis'  Compend  of  Obstetrics.  Illustrated.  4th  edition, 
enlarged.  Cloth,  1.00;   Interleaved  for  Notes,  1.25 

Galabin's  Midwifery.  By  A.  Lewis  Galabin,  m.d.,  f.r.c.p. 
227  Illustrations.     See  page  3.  Cloth,  3.00;  Leather,  3.50 

t&~  See  Paget  2  to  5  for  list  of  New  Manuals. 


STUDENTS'   TEXT-BOOKS  AND   MANUALS.         11 


PATHOLOGY.    HISTOLOGY.    BIOLOGY. 

Bowlby.  Surgical  Pathology  and  Morbid  Anatomy,  for 
Students.     135  Illustrations.     i2mo.  Cloth,  2.00 

Davis*  Elementary  Biology.    Illustrated.  Cloth,  4.00 

Gilliam's  Essentials  of  Pathology.  A  Handbook  for  Students. 
47  Illustrations.     i2mo.  Cloth,  2.00 

*#*  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing 
them  within  easy  comprehension  to  increase  his  interest  in  the  study 
of  the  subject. 

Gibbes'  Practical  Histology  and  Pathology.    Third  Edition. 

Enlarged.     i2mo.  Cloth,  1.75 

Virchow's  Post-Mortem  Examinations.    3d  Ed.    Cloth,  1.00 

PHYSICAL  DIAGNOSIS. 

Fenwick.  Student's  Guide  to  Physical  Diagnosis.  7th 
Edition.     117  Illustrations.     i2mo.  Cloth,  2.25 

Tyson's  Student's  Handbook  of  Physical  Diagnosis.  Illus- 
trated.    12D10.  Cloth,  1.25 

PHYSIOLOGY. 

Yeo's  Physiology.  Fifth  Edition.  The  most  Popular  Stu- 
dents' Book.  By  Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of 
Physiology  in  King's  College,  London.  Small  Octavo.  758 
pages.  321  carefully  printed  Illustrations.  With  a  Full 
Glossary  and  Index.     See  Page  3.  Cloth,  3.00;  Leather,  3.50 

Brubaker's  Compend  of  Physiology.  Illustrated.  Sixth 
Edition.  Cloth,  1. 00;    Interleaved  for  Notes,  1.25 

Stirling.  Practical  Physiology,  including  Chemical  and  Ex- 
perimental Physiology.    142  Illustrations.  Cloth,  2.25 

Kirke's  Physiology.  New  12th  Ed.  Thoroughly  Revised  and 
Enlarged.     502  Illustrations.  Cloth,  4.00;  Leather,  5.00 

Landois'  Human  Physiology.  Including  Histology  and  Micro- 
scopical Anatomy,  and  with  special  reference  to  Practical  Medi- 
cine. Fourth  Edition.  Translated  and  Edited  by  Prof.  Stirling. 
845  Illustrations.  Cloth,  7.00 ;  Leather,  8.00 

"  With  this  Text-book  at  his  command,  no  student  could  fail  in 

his  examination." — Lancet. 

Sanderson's  Physiological  Laboratory.  Being  Practical  Ex- 
ercises for  the  Student.     350  Illustrations.     8vo.  Cloth,  5.00 

PRACTICE. 

Taylor.  Practice  of  Medicine.  A  Manual.  By  Frederick 
Taylor,  m.d.,  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London  ;  Physician  to  Evelina  Hospital  for  Sick  Chil- 
dren, and  Examiner  in  Materia  Medica  and  Pharmaceutical 
Chemistry,  University  of  London.         Cloth,  4.00;  Leather,  5.00 

>|f$a'  See  pages  14  and  IS  for  list  0/  ?  Quiz-Compends  f 


12        STUDENTS'   TEXT-BOOKS  AND  MANUALS. 

Practice  : — Continued. 

Roberts'  Practice.  New  Revised  Edition.  A  Handbook 
of  the  Theory  and  Practice  of  Medicine.  By  Frederick  T. 
Roberts,  m.d.,  m.r.c.p.,  Professor  of  Clinical  Medicine  and 
Therapeutics  in  University  College  Hospital,  London.  Seventh 
Edition.     Octavo.  Cloth,  5.50  ;  Sheep,  6.50 

Hughes.  Compend  of  the  Practice  of  Medicine.  4th  Edi- 
tion. Two  parts,  each,  Cloth,  1.00;  Interleaved  for  Notes,  1.25 
Part  i. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases 

of  the  Stomach,  Intestines,   Peritoneum,  Biliary  Passages,  Liver, 

Kidneys,  etc.,  and  General  Diseases,  etc. 

Part   ii. — Diseases   of   the   Respiratory    System,   Circulatory 

System  and  Nervous  System ;  Diseases  of  the  Blood,  etc. 

Physicians' Edition.    Fourth  Edition.    Including  a  Section 
on  Skin  Diseases.  With  Index.    1  vol.  Full  Morocco,  Gilt,  2.50 

From  John  A.  Robinson,  M.D.,  Assistant  to  Chair  of  Clinical 
Medicine ,now Lecturer  on  Materia  Medica,  Rush  Medical  Col- 
lege, Chicago. 
"  Meets  with   my  hearty  approbation   as   a  substitute  for  the 

ordinary  note  books  almost  universally  used  by  medical  students. 

It  is  concise,  accurate,  well  arranged  and  lucid,     .     .     .    just  the 

thing  for  students  to  use  while  studying  physical  diagnosis  and  the 

more  practical  departments  of  medicine." 

PRESCRIPTION   BOOKS. 

Wythe's  Dose  and  Symptom  Book.  Containing  the  Doses 
and  Uses  of  all  the  principal  Articles  of  the  Materia  Medica,  etc. 
Seventeenth  Edition.  Completely  Revised  and  Rewritten.  Just 
Ready.     32010.  Cloth,  1. 00;   Pocket-book  style,  1.25 

Pereira's  Physician's  Prescription  Book.  Containing  Lists 
of  Terms,  Phrases,  Contractions  and  Abbreviations  used  in 
Prescriptions  Explanatory  Notes,  Grammatical  Construction  ot 
Prescriptions,  etc.,  etc.  By  Professor  Jonathan  Pereira,  m.d. 
Sixteenth  Edition.    32010.     Cloth,  1. 00;  Pocket-book  style,  1.25 

PHARMACY. 

Stewart's  Compend  of  Pharmacy.  Based  upon  Remington's 
Text-book  of  Pharmacy.  Third  Edition,  Revised.  With  new 
Tables,  Index,  Etc.  Cloth,  1.00  ;  Interleaved  for  Notes,  1.25 

Robinson.  Latin  Grammar  of  Pharmacy  and  Medicine. 
By  H.  D.  Robinson,  ph.d.,  Professor  of  Latin  Language  and 
Literature,  University  of  Kansas,  Lawrence.  With  an  Intro- 
duction by  L.  E.  Sayre,  ph.g.,  Professor  of  Pharmacy  in,  and 
Dean  of,  the  Dept.  of  Pharmacy,  University  of  Kansas.     i2mo. 

Cloth,  2.00 
SKIN  DISEASES. 
Anderson,  (McCall)  Skin  Diseases.      A  complete   Text-book, 
with    Colored   Plates   and   numerous    Wood   Engravings.    8vo. 

Cloth,  4.50;  Leather,  5.50 

Van  Harlingen  on  Skin  Diseases.  A  Handbook  of  the  Dis- 
eases of  the  Skin,  their  Diagnosis  and  Treatment  (arranged  alpha- 
betically). By  Arthur  Van  Harlingen,  m.d..  Clinical  Lecturer 
on  Dermatology,  Jefferson  Medical  College ;  Prof,  of  Diseases  of 
the  Skin  in  the  Philadelphia  Polyclinic.  2d  Edition.  Enlarged. 
With  colored  and  other  plates  and  illustrations.  i2mo.  Cloth,  2.50 
J1&-  See  pages  2  to  5  for  list  0/ New  Manuals. 


STUDENTS'   TEXT-BOOKS  AND  MANUALS.        13 

SURGERY   AND    BANDAGING. 

Moullin's  Surgery.  500  Illustrations  (some  colored),  200  of 
which  are  original.  Cloth,  net  7.00;  Leather,  net  8.00 

Jacobson.  Operations  in  Surgery.  A  Systematic  Handbook 
for  Physicians,  Students  and  Hospital  Surgeons.  By  W.  H.  A. 
Jacobson,  b.a.  Oxon.,  f.r.c.s.  Eng. ;  Ass't  Surgeon  Guy's  Hos- 
pital ;  Surgeon  at  Royal  Hospital  for  Children  and  Women,  etc. 
199  Illustrations.     1006  pages.     8vo.      Cloth.  5.00;  Leather,  6.00 

Heath's  Minor  Surgery,  and  Bandaging.  Ninth  Edition.  142 
Illustrations.     60  Formulae  and  Diet  Lists.  Cloth,  2.00 

Horwitz's    Compend    of    Surgery,    Minor     Surgery    and 
Bandaging,    Amputations,    Fractures,    Dislocations,   Surgical 
Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential 
Diagnosis  and  Treatment.     By  Orville  Hokwitz,  b.s.,  m.d., 
Demonstrator  of  Surgery,  Jefferson  Medical  College.    4th  edition. 
Enlarged  and  Rearranged.     136   Illustrations   and   84  Formulae. 
i2mo.         Cloth,  1.00;  Interleaved  for  the  addition  of  Notes,  1.25 
*#*  The  new  Section  on  Bandaging  and  Surgical  Dressings,  con- 
sists   of  32   Pages  and   41    Illustrations.     Every  Bandage  of   any 
importance   is  figured.      This,  with    the  Section  on  Ligation  oi 
Arteries,  forms  an  ample  Text-book  for  the  Surgical  Laboratory. 

Walsham.  Manual  of  Practical  Surgery.  Third  Edition. 
By  Wm,  J.  Walsham,  m.d.,  f.r.c.s.,  Asst.  Surg,  to,  and  Dem 
of*  Practical  Surg,  in,  St.  Bartholomew's  Hospital ;  Surgeon  to 
Metropolitan  Free  Hospital,  London.  With  318  Engravings. 
See  Page  2.  Cloth,  3.00;  Leather,  3.50 

URINE,  URINARY   ORGANS,  ETC. 

Holland.  The  Urine,  and  Common  Poisons  and  The 
Milk.  Chemical  and  Microscopical,  for  Laboratory  Use.  Illus- 
trated.    Fourth  Edition.     12010.     Interleaved.  Cloth,  1.00 

Ralfe.  Kidney  Diseases  and  Urinary  Derangements.  42  Illus- 
trations.    i2mo.     572  pages.  Cloth,  2.75 

Marshall  and  Smith.  On  the  Urine.  The  Chemical  Analysis  ot 
the  Urine.  By  John  Marshall,  m.d.,  Chemical  Laboratory,  Univ. 
of  Penna;  and  Prof.  E.  F.  Smith,  ph. d.  Col.  Plates.    Cloth,  1. 00 

Memminger.     Diagnosis  by  the  Urine.    Illustrated. 

Cloth,  1. 00 

Tyson.  On  the  Urine.  A  Practical  Guide  to  the  Examination 
of  Urine.  With  Colored  Plates  and  Wood  Engravings.  7th  Ed. 
Enlarged.    i2mo.  Cloth,  1.50 

Van  Niiys,  Urine  Analysis.    Illus.  Cloth,  2.00 

VENEREAL  DISEASES. 

Hill  and  Cooper.  Student's  Manual  of  Venereal  Diseases, 
with  Formulas.    Fourth  Edition.     i2mo.  Cloth,  1.00 

See  pages  14  and  if  for  list  of  f  Quiz-  Cotnpends  f 


NEW  AND  REVISED  EDITIONS. 

PQUIZ-COMPENDS? 

The  Best  Compends  for  Students'  Use 
in  the  Quiz  Class,  and  when  Pre- 
paring for  Examinations. 

Compiled  in  accordance  with  the  latest  teachings  of  promi- 
nent lecturers  and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical  and  exhaustive 
set  of  manuals,  containing  information  nowhere  else  col- 
lected in  such  a  condensed,  practical  shape.  Thoroughly 
up  to  the  times  in  every  respect,  containing  many  new 
prescriptions  and  formulae,  and  over  two  hundred  and 
fifty  illustrations,  many  of  which  have  been  drawn  and 
engraved  specially  for  this  series.  The  authors  have  had 
large  experience  as  quiz-masters  and  attaches  of  colleges, 
with  exceptional  opportunities  for  noting  the  most  recent 
advances  and  methods. 

Cloth,  each  $1.00.     Interleaved  for  Notes,  $1.25. 

No.  1.  HUMAN  ANATOMY,  "Based  upon  Gray."  Fifth 
Enlarged  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  16  Lithograph  Plates,  New 
Tables  and  117  other  Illustrations.  By  Samuel  O.  L. 
Potter,  m.a.,  m.d.,  m.r.c.p.  (Lond.),  late  A.  A.  Surgeon  U.  S. 
Army,  Professor  of  Practice,  Cooper  Medical  College,  San  Fran- 
cisco. 

Nos.  2  and  3.  PRACTICE  OF  MEDICINE.  Fourth  Edi- 
tion. By  Daniel  E.  Hughes,  m.d.,  Demonstrator  of  Clinical 
Medicine  in  Jefferson  Medical  College, Philadelphia.  In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 
Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (including  Phy- 
sical Diagnosis),  Circulatory  System  and  Nervous  System;  Dis- 
eases of  the  Blood,  etc. 

***  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon 
the  Practice  of  Medicine,  containing  the  Synonyms,  Definitions, 
Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each 
disease,  and  including  a  number  of  prescriptions  hitherto  unpub- 
lished. 
No.    4.      PHYSIOLOGY,    including     Embryology.     Sixth 

Edition.    By  Albert  P.  Brubaker,  m.d.,  Prof,  of  Physiology, 

Penn'a  College  of  Dental  Surgery ;  Demonstrator  of  Physiology 

in  Jefferson  Medical  College,  Philadelphia.    Revised,  Enlarged, 

with  new  Illustrations. 

No.  5.  OBSTETRICS.  Illustrated.  Fourth  Edition;  By 
Henry  G.  Landis,  m.d.,  Prof,  of  Obstetrics  and  Diseases  of 
Women,  in  Starling  Medical  College,  Columbus,  O.  Revised 
Edition.     New  Illustrations. 


BLAKISTON'S  ?  QUIZ-COMPENDS  ? 

No.  6.  MATERIA  MEDICA,  THERAPEUTICS  AND 
PRESCRIPTION    WRITING.     Fifth   Revised   Edition. 

With  especial  Reference  to  the  Physiological  Action  of  Drugs, 
and  a  complete  article  on  Prescription  Writing.  Based  on  the 
Last  Revision  of  the  U.  S.  Pharmacopoeia,  and  including  many 
unofficinal  remedies.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
m.r.c.p.  (Lond.),  late  A.  A.  Surg.  U.  S.  Army ;  Prof,  of  Practice, 
Cooper  Medical  College,  San  Francisco.  Improved  and  Enlarged, 
with  Index. 

No.  7.  GYNAECOLOGY.  A  Compend  of  Diseases  of  Women. 
By  Henry  Morris,  m.d.,  Demonstrator  of  Obstetrics,  Jefferson 
Medical  College,  Philadelphia.      45  Illustrations. 

No.  8.     DISEASES  OF  THE  EYE  AND  REFRACTION, 

including  Treatment  and  Surgery.  By  L.  Webster  Fox,  m.d., 
Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Med- 
ical College,  etc.,  and  Geo.  M.  Gould,  m.d.  71  Illustrations,  39 
Formulae.     Second  Enlarged  and  improved  Edition.    Index. 

No.  9.  SURGERY,  Minor  Surgery  and  Bandaging.  Illus- 
trated. Fourth  Edition.  Including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other  operations  ;  Inflam- 
mation, Suppuration,  Ulcers,  Syphilis,  Tumors,  Shock,  etc. 
Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d., 
Demonstrator  of  Surgery,  Jefferson  Medical  College.  Revised 
and  Enlarged.     84  Formulas  and  136  Illustrations. 

No.  10.  CHEMISTRY.  Inorganic  and  Organic.  For  Medical 
and  Dental  Students.  Including  Urinary  Analysis  and  Medical 
Chemistry.  By  Henry  Leffmann,  m.d.,  Prof,  of  Chemistry  in 
Penn'a  College  of  Dental  Surgery-,  Phila.  Third  Edition,  Revised 
and  Rewritten,  with  Index. 

No.  11.  PHARMACY.  Based  upon  "  Remington's  Text-book 
of  Pharmacy."  By  F.  E.  Stewart,  m.d.,  ph. g.,  Quiz-Master 
at  Philadelphia  College  of  Pharmacy.     Third  Edition,  Revised. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOL- 
OGY. 29  Illustrations.  By  Wm,  R.  Ballou,  m.d.,  Prof,  of 
Equine  Anatomy  at  N.  Y.  College  of  Veterinary  Surgeons. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDI- 
CINE. Containing  all  the  most  noteworthy  points  of  interest 
to  the  Dental  student.  By  Geo.  W.  Warren,  d.d.s.,  Clinical 
Chief,  Penn'a  College  of  Dental  Surgery,  Philadelphia.     Illus. 

No.  14.  DISEASES  OF  CHILDREN.  By  Dr.  Marcus  P. 
Hatfield,  Prof,  of  Diseases  of  Children,  Chicago  Medical 
College.     Colored  Plate. 

Bound  in  Cloth,  $1.    Interleaved,  for  the  Addition  of  Notes,  $1.25. 

J5^I>  These  books  are  constantly  revised  to  keep  up  with 
the  latest  teachings  and  discoveries,  so  that  they  contain 
all  the  new  methods  and  principles.  No  series  of  books 
are  so  complete  in  detail,  concise  in  language,  or  so  well 
printed  and  bound.  Each  one  forms  a  complete  set  of 
notes  tipon  the  subject  under  consideration. 

Illustrated  Descriptive  Circular  Free. 


JUST  PUBLISHED. 


GOULD'S  NEW 

Medical  Dictionary 


compact. 

CONCISE. 

PRACTICAL. 

ACCURATE. 

COMPREHENSIVE 

UP  TO  DATE. 


It  contains  Tables  of  the  Arteries,  Bacilli,  Gan- 
glia,    Leucomaines,    Micrococci,    Muscles, 
Nerves,    Plexuses,    Ptomaines,    etc., 
etc.,  that  will  be  found  of  great 
use   to   the    student. 


Small  octavo,  520  pages,  Half-Dark  Leather,      .     #3.25 
With  Thumb  Index,  Half  Morocco,  marbled  edges,  4.25 


From  J.  M.  DaCOSTA,  M.  D.,   Professor  of  Practice  and 
Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"I find  it  an  excellent  work,  doing  credit  to  the  learning  and 
discrimination  0/  the  author." 

***  Sample  Pages  free. 


A 


COLUMBIA  UNIVERSITY 

This   book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

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B98 
1892 


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